‘Taking ACTion on Anger’: A School Perspective of the

Feasibility and Preliminary Efficacy of a Brief ACT

Intervention for Anger in Adolescent Males

Hannah Marie Parker

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, Surrey

United KingdomSeptember 2017

1

STATEMENT OF ORIGINALITY

This thesis and the work to which it refers are the results of my own efforts. Any ideas, data,

images, or text resulting from the work of others (whether published or unpublished) are fully

identified as such within the work and attributed to their originator in the text. This thesis has

not been submitted in whole or in part for any other academic degree or professional

qualification.

Name: Hannah Marie Parker

2

OVERVIEW

The mental health needs of adolescents are of growing concern with high prevalence rates,

there is an increasing need for early intervention. Anger difficulties are a particular issue for

adolescent males, leading to school exclusion and behavioural rather than emotional

support. If untreated, maladaptive responses to anger can lead to significant problems in

adulthood, including violence and crime. Acceptance and commitment therapy (ACT) is a 3rd

wave behavioural therapy which can be adapted to the specific social and developmental

needs of adolescents. This thesis aimed to develop and trial an ACT intervention for anger

difficulties with adolescent males in a school context.

Research part one of this thesis presents a systematic literature review of ACT interventions

for adolescents. The studies identified highlighted the infancy of the adolescent ACT

literature, with all but one of the studies published since 2011. The studies were largely

feasibility or pilot research, and most suffer from a lack of power and methodological issues.

Despite these concerns the interventions show promise for the application of ACT to

adolescents.

Research part two presents an empirical paper of a novel school-based ACT intervention for

adolescent males with mild anger difficulties. The study investigates the feasibility of

delivering the intervention in a school setting and the effectiveness of the intervention from

the school perspective. Quantitative findings show significant decreases in school penalties

and teacher observed emotional difficulties; however only cautionary interpretations can be

made due to the study being underpowered. Qualitative findings noted changes of the boys

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reflecting and taking ownership over their behaviour, and highlight the importance of the

teacher-student relationship whilst positioning the findings within the wider system.

Qualitative feasibility findings emphasise the importance of embedding the intervention

within the pre-existing school system. Suggestions for future developments are provided.

Part three presents a summary of the clinical experience gained over the course of the

doctoral training. Part four details a table of the academic assessments completed over the

three years.

4

PUBLICATIONS / PRESENTATIONS ARISING FROM THE MRP

Parts of this thesis have been presented in:

Parker*, H. M., Livings*, J., & John, M. (2016, November). Taking ACTion on Anger: A

feasibility study of a novel ACT-based anger intervention for adolescent males delivered in a

school setting. Poster session presented at the Third BABCP ACT SIG / ACBS UK & Ireland

Chapter Contextual Behavioural Science Conference, Edinburgh, UK.

5

TABLE OF CONTENTS

Table of Contents Page Number

Acknowledgements 7

Research Part 1 – Literature Review 9-63

Abstract 10

Introduction 11

Method 17

Results 22

Discussion 43

References 51

Research Part 2 – MRP Empirical Paper 65-130

Abstract 65

Introduction 66

Method 73

Results 83

Discussion 103

Reference 115

Appendices 124

Part 3 – Summary of Clinical Experience 165

Part 4 – Table of Assessments Completed During Training 168

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RESEARCH PART 2: MRP EMPIRICAL PAPER APPENDICES Page

Appendix 1 Ethical Approval 125

Appendix 2 Information and Consent Forms 126-135

Appendix 2a Teacher Information Sheet 126

Appendix 2b Teacher Consent Form 128

Appendix 2c Adolescent Participant Information Sheet 129

Appendix 2d Adolescent Participant Consent Form 132

Appendix 3 Information Letter to Parents 133

Appendix 4 Teacher Strengths and Difficulties Scale (T-SDQ) 135

Appendix 5 Interview Schedules 136-139

Appendix 5a Pre Study Feasibility Interview Schedule 136

Appendix 5b Post Study Feasibility Interview Schedule 137

Appendix 5c Informant Teacher Post Intervention Interview Schedule with Feasibility Questions

138

Appendix 5d Informant Teacher Follow-Up Intervention Interview Schedule

139

Appendix 5e Informant Teacher Post study Feasibility Questions 139

Appendix 6 Intervention Protocol 140

Appendix 7 Histograms Examining the Distribution of data 151

Appendix 8 Raw Scores of Reliable and Clinically Significant Change for Adolescent Participants

158

Appendix 9 Example extracted codes from effectiveness interviews 159

Appendix 10 Example extracted codes from feasibility interviews 162

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ACKNOWLEDGEMENTS

There are many people I would like to acknowledge for their help and guidance throughout

this project.

Firstly I wish to thank the unrelenting support, motivational pep talks and helpful advice

provided by my main supervisor, Mary John. Who despite being one of the busiest women I

have known, always made time for me. My thanks also goes to my second supervisor, Linda

Morison for her incredible stats mind and practical advice. To my good friend and co-

designer of the intervention, Jenny. Thank you for your remarkable organisation and pro-

active approach, your infectious sense of humour, love of ACT, consistent support and ability

to carry everything we could have ever needed with you in several bags; truly a sight to

behold!

I would like to thank my family for always believing in me on this lengthy journey,

particularly when I doubted myself. All my friends who have been patiently waiting for my

social life to return, offering words of encouragement, and always being available whenever

I’ve needed them. Particular thanks goes to my fellow trainees Caroline and Alison, for

understanding and always being there; Monday’s will forever be our day. Boycie and

Hobbes, thank you for getting me through the long study days. To my partner Siôn, thank

you for being amazing throughout this process; providing me with unlimited food and hot

drinks. For being my butler, cleaner, cook, steadying me when I began to wobble, making me

laugh when I needed it most and encouraging and believing in me throughout.

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I would like to thank Melanie Orchard who kindly advised us on the adherence of our group

protocol to the ACT model. Also, my thanks go to our focus group of adolescent boys, who

consulted on the acceptability of the program as we were developing initial ideas and

metaphors.

Finally I would like to thank the school, for allowing us to deliver the intervention. In

particular, the teachers who kindly made time in their busy schedules to answer my

questions and complete questionnaires and the co-facilitators for their enthusiasm for the

project. Most importantly my thanks goes to the boys who participated in the group and

bought our vision to life with their lively personalities, imagination, original vocabulary and

fantastic sense of fun.

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RESEARCH PART ONE - L ITERATURE REVIEW

T ITLE : Acceptance and Commitment Therapy for Adolescent Mental Health: A Systematic

Review.

WORD COUNT : 7112

.

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ABST RAC T

Prevalence rates of mental health difficulties in UK youth are high and increase with age. The

majority of lifetime mental health difficulties emerge by adolescence and young adulthood.

Even sub-clinical difficulties occurring in adolescence can have detrimental impact upon

future social, health and financial well-being. This age group requires interventions tailored

to the specific developmental, social and emotional changes occurring in adolescence.

Acceptance and commitment therapy (ACT) offers an intervention, which can be adapted to

suit to these requirements. The current systematic review explored all peer-reviewed

literature of ACT interventions with adolescents addressing emerging or pre-existing mental

health difficulties. Searches produced 21 articles, which covered 20 intervention studies. All

studies were assessed for methodological quality, effectiveness and acceptability. The most

striking factor was the recentness of the articles, with all but one published after 2011. In

line with this emerging field of literature, the majority were described as pilot, feasibility or

preliminary research. Methodological weaknesses and small sample sizes resulted in

cautionary interpretations of findings, however many studies offered preliminary support for

the use of ACT with adolescents. Directions for future research are discussed.

Keywords: acceptance and commitment therapy, adolescence, intervention, mental health

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INT RODUCT ION

Worldwide it is estimated that 20% of adolescents will experience a mental health difficulty

(World Health Organisation, 2003). Assessing the prevalence of mental health difficulties in

UK youth is challenging as national surveys are out-dated, with the most recent occurring

over a decade ago in 2004 (Green, Mcginnity, Meltzer, Ford & Goodman, 2005). At that time

prevalence increased with age, from 8% of 5-10 year olds, growing to 12% of 11-16 year

olds. This rate rises steeply to 20% in 16-24 year olds (Sainsbury & Goldman, 2011). A more

recent cross-sectional comparison of 11-13 year olds in England found similar levels of

mental health difficulties in both 2009 and 2014 cohorts (Fink, Patalay, Sharpe, Holley,

Deighton & Wolpert, 2015), indicating stability across prevalence rates. To add to this high

prevalence, the majority of lifetime mental health difficulties are evident by adolescence and

young adulthood; 50% have emerged by 14 years old and 75% by 24 years (Kessler,

Berglund, Demler, Jin, Merikangas, Walters, 2005). The high prevalence and early onset of

difficulties strengthens the importance of providing appropriate and effective mental health

treatment in adolescence.

Despite the importance of effective treatments, estimates suggest that only 4% of 10-17

year olds are referred to specialist mental health services per year, and of these up to a third

of received referrals are not accepted (Abdinasir & Pona, 2015). These figures indicate that

not only are many adolescents not receiving appropriate treatment, but also many mental

health difficulties are not being identified. Across all ages, mental health is estimated to cost

the UK £105 billion per year, despite this huge financial cost just 0.7% of NHS budget is spent

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on young people’s mental health (Mental Health Task Force, 2016). Fortunately the UK

government is beginning to take notice of the need for improvements and in 2015 made a 5-

year commitment to spend £1.25 billion on improving children and young people’s mental

health (YoungMinds, 2016). This recent investment offers opportunities for developing

effective adolescent-tailored interventions.

Young people with diagnosed mental health difficulties are more likely to have time off

school, particularly unauthorised absences (Green et al., 2005). Time away from school not

only reduces prospects for academic endeavours, but also limits social developmental

opportunities. Youth mental health difficulties, including those below diagnostic thresholds,

are associated with increased social, health, financial and legal adversities in adulthood;

irrespective of whether the mental health difficulty continues into adulthood (Copeland,

Wolke, Shanahan & Costello, 2015). Copeland et al.’s (2015) longitudinal study also found

that exposure to further mental health difficulties worsened prognosis. Mental health

difficulties affect many facets of an adolescent’s life and future prospects; therefore it is

imperative to identify effective adolescent-specific psychological interventions targeted at

both diagnosed and sub-clinical mental health difficulties.

Adolescence occurs between 10-19 years, it is a time of physical, emotional, social and

neurodevelopmental turbulence (Blakemore, 2008; Casey, Jones & Hare, 2008). Adolescents

engage in more risk-taking behaviours, become less concerned with parental influence

instead favouring the opinions of their peer group, and strive for autonomy in the pursuit of

developing their identity (Casey et al., 2008; Erickson, 1993). Cognitive changes during

adolescence mean that young people develop ability for abstract thinking (Piaget, 1976).

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These changes mean adolescents require psychological interventions specifically designed

for them, flexible to developmental changes, enabling autonomy, and sensitivity to peer-

influence. Moreover, group interventions must be adaptable to different stages of

developmental maturation across group members.

Current national guidance created by the National Institute of Health and Clinical Excellence

(NICE) for tackling mental health difficulties in adolescence largely centre around

pharmacological and Cognitive Behavioural Therapy (CBT) interventions for anxiety disorders

and depression (Stallard, Udwin, Goddard & Hibbert, 2007). For more severe difficulties,

intensive specialist interventions are recommended such as multi-modal systemic therapy

(MST) for adolescents displaying aggressive and antisocial behaviour (NICE, 2013). Within

the last decade NICE has also published guidance on the role of secondary schools in

identifying organisation wide curriculum to support the development of social and

emotional skills (NICE, 2009).

Borne out of NICE approved CBT, Acceptance and Commitment Therapy (ACT) is a third-

wave behavioural therapy. It is based upon theoretical underpinnings of relational frame

theory (RFT) and functional contextualism (for further information see Hayes, 2004; Hayes,

Luoma, Bond, Masuda & Lillis, 2006; Ramnerö & Törneke, 2008). In brief, RFT emphasises

the role of human language acquisition and cognition, namely the importance of

associations made between words and events. Functional contextualism is the philosophical

stance behind RFT, (Hoffman and Asmundson, 2008) which highlights the importance of

context, and the function of internal experiences (thoughts, emotions, memories, sensations

etc.). In ACT human thinking is seen as behaviour, cognitions are internal experiences that

14

are labelled with language (Hayes et al., 2006). According to ACT, internal experiences

become problematic due to the context in which they take place, rather than the frequency,

form or belief in these phenomena (Hayes et al., 2006; Hayes, Masuda, Bissett, Luoma &

Geurrro, 2004). For example, problems arise if a person attempts to exert control or explain

their private events rather than experiencing them with curiosity (Harris, 2009). Therefore

the focus of therapy is on a person’s relationship with internal experiences, rather than

attempts to alter them, a key difference with CBT.

ACT posits that a literal interpretation of a thought can result in “fusion” with that thought; if

the thought is for example, “I am useless” this can lead to pain and suffering (Harris, 2009).

Pain causes people to want to avoid experiencing this difficult internal experience, resulting

in “experiential avoidance” (Hayes, Strosahl & Wilson, 1999). Experiential avoidance causes

people to close down and lose contact with the present moment as a means of avoiding

distress, however in doing so individuals lose sight of what is important to them, i.e. their

values (Harris, 2009).

ACT attempts to overcome distress caused by experiential avoidance by encouraging

“psychological flexibility”, that is, “the ability to be in the present moment with full

awareness and openness to our experience and to take action guided by our values” (Harris,

2009, p.12). This is achieved using six core processes known as the ACT hexaflex, which

Harris (2009) has simplified into three processes known as the ACT triflex, namely:

1. ‘Being present’, referring to being consciously in touch with the present moment and

noticing that you are able to experience internal events, and also observe those

events. Mindfulness is a method used to support present moment awareness.

15

2. ‘Doing what matters’ refers to knowing your values and committing to choose

actions, which are in line with them.

3. ‘Opening up’ is making room for and exploring difficult internal experiences, through

acceptance and “defusion” or separating oneself from difficult thoughts.

ACT differs from its CBT predecessor in a number of ways, which make it apt for adolescents

(see Halliburton & Cooper, 2015 for detailed review.) Firstly, the emphasis on values and

committed action focuses treatment on the adolescent in their wider context, as opposed to

a predominantly symptom-reduction focus found in CBT (Hoffman and Asmundson, 2008).

Adolescence is a time of transition and drive for autonomy, focussing upon personal values

allows the adolescent to choose their own direction for therapy, empowering them to bring

about change. As mental health difficulties often arise in adolescence (Kessler et al., 2005),

focussing on the wider context rather than a problem-directed approach is also applicable to

emerging difficulties. Finally, it’s emphasis on increasing psychological flexibility and

reducing experiential avoidance means that the therapy is very active and less reliant on

talking; it uses experiential exercises and metaphor to portray and trial key ideas with the

client, which are particularly encouraged when working with adolescents (Greco, Blackledge,

Coyne & Enreheich, 2005). To support the cognitive shift from concrete towards abstract

thinking during adolescence, ACT’s use of experiential activities and physical objects to

describe metaphors can help link abstract concepts to concrete examples, thus bridging this

developmental transition (Halliburton & Cooper, 2015; Piaget, 1976).

Meta-analyses of randomised controlled trials (RCTs) of ACT interventions have found

moderate (e.g. Öst, 2014; Powers, Zum Vorde Sive Vording & Emmelkamp, 2009) to large

16

mean effect sizes (ES; e.g. Hayes et al., 2006; Öst, 2008) compared to wait-list or treatment

as usual (TAU) conditions. Öst’s (2014) recent meta-analysis found ACT to be probably

efficacious for tinnitus and chronic pain, and possibly efficacious for psychosis, mixed

anxiety, OCD, depression, occupational stress and substance misuse. However, this was in a

predominantly adult sample and only included two studies with young people, targeting

chronic pain (Wicksell, Melin, Lekander & Olsson, 2009) and depression (Hayes, Boyd &

Sewell, 2011). Findings have been mixed in meta-analyses comparing ACT to existing

treatments, including CBT. Some have found ACT is no more efficacious than established

treatments, including CBT (Öst, 2014; Powers et al., 2009). Whilst Ruiz (2012) found a

significant mean ES of 0.37 favouring ACT over CBT interventions. Additionally, ACT studies

have been repeatedly critiqued for poor methodological quality (Öst, 2008; 2014).

In regards to youth specific literature, one systematic review examined studies for a broad

age range from 6-18 years, across mental and physical health difficulties (Swain, Hancock,

Dixon & Bowman, 2015a). The authors concluded there was emerging evidence for ACT

across a range of difficulties in children. Another review explored developmental adaptations

when applying ACT protocols to adolescents, it included a brief review of 10 studies across

chronic pain, developmental disorders and mental health difficulties and found all

participants across studies experienced differing degrees of symptom improvement

(Halliburton & Cooper, 2015). As with previous reviews they noted various methodological

limitations but no formal evaluation of methodological quality was carried out.

To date, no systemic review of the literature has investigated the applications of ACT to

existing and emerging mental health difficulties in adolescents, along with a thorough

17

investigation of methodological quality.

Aims and Review Questions

The aim of the current review was to examine peer-reviewed literature using ACT

interventions with adolescents to address emerging and existing mental health difficulties.

The review examined methodological quality across studies, treatment effectiveness and

acceptability.

Specific research questions include:

1. How effective are ACT interventions for adolescents?

a. How methodologically robust are these studies?

b. What is the size of effect with these groups?

c. What is the impact on ACT processes?

2. How acceptable have these interventions been to the adolescents?

MET HOD

Searching Procedure

Electronic searches were conducted across nine databases of interest, Association for

Contextual and Behavioural Science publications, Child Development & Adolescent Studies,

Cochrane Collaboration, ERIC, MEDLINE, PsycArticles, PsycInfo, Psychology & Behavioural

Sciences Collection and Web of Science. The databases were searched for literature using

the following search terms of ‘Adolescent’ and ‘Acceptance and Commitment Therapy’ in

the abstract and/or subject terms. The format of search terms was adapted for each

18

database; specific terms and limiters are detailed in table 1. The search was conducted in

July 2017 with no limit placed on the publication date to incorporate all available articles. In

addition, manual searches of reference lists from any relevant review articles were

conducted.

Table 1

Search Terms Table

Generic term Specific Search Terms

Adolescent youth* OR juvenil* OR teen* OR young* OR adolescen* OR boy* OR girl* OR pupil* OR child* OR student*- all contained in the abstract

ACT “acceptance and commitment therapy” – contained in the abstract OR“acceptance and commitment therapy” – contained in the subject terms ORdefusion – contained in the abstract

Initial searches produced 721 articles, 98 of these were duplicates, leaving 623 that

progressed to the screening stages. Articles underwent a title, abstract and full text screen

using the inclusion and exclusion criteria detailed in table 2.

Table 2

Participant inclusion and Exclusion Criteria

Inclusion Criteria

1. Intervention studies that evaluated the effectiveness of an ACT intervention with adolescents between 11-18 years. If this age range was exceeded then mean age plus 1 standard deviation must fall within this range.

2. The intervention had to be evaluated with at least one outcome measure with reliable psychometric properties.

3. The ACT intervention included at least two components of Harris’s (2009) Tri-flex; namely, ‘be present’ (contact with the present moment / self-as-context), ‘do what matters’ (values / committed action), ‘open up’ (defusion / acceptance).

Exclusion Criteria

1. Non-peer reviewed articles e.g. unpublished doctoral theses2. Participants with a diagnosis of an intellectual disability or autism spectrum disorder3. Participant main difficulty was related to physical health including chronic pain4. Target of the intervention was not related to mental health e.g. sports improvement5. Article was not written or translated into English6. ACT interventions which included more than one additional component or model, e.g. Mode

Deactivation Therapy (MDT) which comprises parts of ACT, Dialectical Behavioural Therapy (DBT), and Functional Analytic Therapy (FAP)

Figure 1 shows a flow chart detailing the number of articles removed at each stage and

reasons for exclusion.

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Evaluation of Articles

The screening stages produced 21 eligible articles. To address the aims of the review,

evaluations of methodological rigour, an appraisal of results on primary outcome measures

and ACT process measures, and acceptability data incorporating attrition, was executed on

all studies.

Evaluation of methodology

Methodological rigor was assessed using the Psychotherapy Outcome Study Methodology

Records identified through manual searches

(n = 2)

Excluded at Full Text Screen(54)

Reviews = 10Includes Multiple Models = 8

Not Adolescents = 15Not Evaluation of Intervention = 9

Not Peer Reviewed = 6Health/Pain = 4

Not English Language = 2

Records moved to Abstract Screening(n = 394)

Excluded at Abstract Screen(321)

Duplicates = 14Not Adolescents =180

Not Evaluation of Intervention =77Health/Pain = 17

Not in English = 12ASD/LD = 9

Not Relevant =8 No Psychometrics =2

Non Mental Health = 2

Excluded at Title Screen(229)

Duplicates = 72Not Evaluation of Intervention =

60Not Adolescents = 64

Not Relevant = 21

Duplicates Excluded(98)

Records Included in Literature Review(n = 21)

Records moved to Full Text Screening(n = 73)

Records moved to Title Screening(n = 623)

Records identified through initial database searches(n = 721)

Figure 1. Eligible Studies

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Rating Form (POSMRF; Öst, 2008). This methodological quality assessment tool was selected

as it has been used in other systematic reviews of the ACT literature for adults and children,

(see Öst, 2008, 2014; Smout, Hayes, Atkins, Klusen & Duguid, 2012; Swain et al., 2013; Swain

et al., 2015a). The scale is developed for intervention studies, it has 22 items which are rated

as poor=0; 1=fair; 2=good. The POSMRF items assess the following areas: clarity of sample

description; severity/chronicity of the disorder; representativeness of the sample; reliability

of the diagnosis in question; specificity of outcome measures; reliability and validity of

outcome measures; use of blind evaluators; assessor training; assignment to treatment;

design; power analysis; assessment points; manualised, replicable, specific treatment

programs; number of therapists; therapist training/experience; checks for treatment

adherence; checks for therapist competence; control of concomitant treatments (e.g.

medications); handling of attrition; statistical analyses and presentation of results; clinical

significance; equality of therapy hours. The scale has shown sound preliminary psychometric

properties on a small sample, including good internal consistency (Cronbach’s alpha = 0.86)

and inter-rater reliability with total score intra-class correlation=0.92; and mean kappa

coefficients on individual items=0.75 (Öst, 2008).

Evaluation of primary and process outcomes

To allow for comparison of outcomes across studies, effect sizes were generated for primary

outcome measures and ACT process measures on samples with 7 or more participants in

each group. Where a primary outcome measure was not indicated, the researcher selected a

measure that assessed the target problem. In some instances more than one measure was

selected; for example, on Burckhardt, Manicavasagar, Batterham & Hadzi-pavlovic’s (2016)

two measures were selected as the depression anxiety stress scale (DASS) was only reported

21

for a subsample with high baseline scores, the second well-being measure selected

incorporated all participants. ACT processes included measures of acceptance, mindfulness,

psychological flexibility, experiential avoidance, and values.

For studies with a comparison group, controlled effect sizes were calculated using the

recommended dpp2 formula (Morris, 2008) for post and follow-up data points, see figure 2.

< NB. Figure 2 has been removed to avoid breaches of copyright >

Figure 2. Formula for calculating controlled effect sizes, taken from Morris (2008).

For studies with only one group, within group pre-post and pre-follow-up uncontrolled effect

sizes were calculated using the formula in figure 3, (Öst, 2008).

< NB. Figure 3 has been removed to avoid breaches of copyright >

Figure 3. Formula for calculating uncontrolled effect sizes for within group pre-post, pre-follow up comparisons, taken from Öst (2008).

For studies with small samples below 7 in each group a narrative discussion of primary and

process outcomes was given.

Evaluation of acceptability data

Finally any quantitative or qualitative data assessing acceptability of the ACT interventions,

along with attrition data was collated and examined.

RESULT S

The search strategy identified 21 articles, which were published between 2002 and 2017. Of

these, one article comprised two studies; depression in an Australian cohort and stress in a

22

Swedish cohort (Livheim et al., 2015). Two further papers were reporting on subsamples

from other identified articles (Swain Hancock, Hainsworth & Bowman, 2015b; Merwin,

Zucker & Timko, 2013). Swain et al., (2015b) detailed a mediation analysis of ACT process

measures on an adolescent subsample from a larger RCT by Hancock et al., (2016) which also

included younger children. Merwin et al., (2013) provides an account of treatment and

individual data on the first 6 families which are included in a larger trial sample reported by

Timko, Zucker, Herbert, Rodriguez & Merwin (2015). To avoid duplicate reporting, only

Swain et al.’s (2015b) adolescent data and Timko et al.’s (2015) larger sample were discussed

in the review, and Livheim et al.’s (2015) samples were examined separately. In total 20

samples of adolescents were included, table 3 provides an overview of the studies.

The following sections will detail a) evaluation of methodological robustness across all

studies, b) examination of outcomes and ACT processes, c) acceptability of interventions for

adolescents.

Total Number of Participants & Publication Date

The 20 studies account for 1447 adolescents, of which 767 were enrolled to receive an ACT

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Table 3

Overview of Included Studies

Study & Country Difficulty Design Treatment Participants Ethnicity n (%)

Armstrong et al., 2013 - USA

OCD Case Series ACT vs baseline ctrl3 individual sessions; Clinic setting

n=3, n male=2 (67%)Age 12-13yrs, mean 12.3, sd 0.58

no info.

Azadeh et al., 2016 - Iran Social Anxiety Between Group

ACT vs no treatment ctrl10x90min group sessions; School setting

n= 30 (15+15), n male= 0 (0%)Age 15-16yrs, mean 15.43, sd 0.78

no info.

Burckhard et al., 2016 - Australia

preventative universal RCT ACT + Positive Psychology vs TAU (pastoral care curriculum)6x30min whole class sessions; School setting

n= 267 (139+128), n male=162 (61%)Age 15-18yrs, mean 16.37

no info.

Burckhard et al., 2017 - Australia

preventative universal Between Group

ACT vs TAU (pastoral care curriculum)7x25min psychologist-led workshop, approx. 60 students + 4x25min teacher-led practical exercises, approx. 15 students; School setting

n= 48 (17+31), n male= 28 (58%)Age 14-16yrs, mean 15.64

no info.

Fine et al., 2012 - USA Trichotillamania Case Study Acceptance Enhanced Behavioural Therapy (no comparison group)11-12 individual sessions; Clinic setting

n=2, n male=0 (0%)Age 15 -16yrs, mean 15.5, sd 0.71

white 2 (100)

Franklin et al., 2011 - USA Tourette Syndrome Between Group

ACT + Habit Reversal Training (HRT) vs HRT aloneACT + HRT = 8 individual sessions, HRT alone = 12 individual sessions; Clinic setting

n= 13 (6+7), n male= 11 (85%)Age 14-18yrs, mean 15.4, sd 1.3

white 10 (77), black 2 (15), other 1 (8)

Gomez et al., 2014 - Spain

Conduct Disorder and Impulsivity

Case Series ACT vs baseline ctrl4x90min individual sessions; School setting

n= 5, n male= 3 (60%)Age 15-17yrs, mean 15.8, sd 0.84

no info.

Hayes et al., 2011 - Australia

Depression RCT ACT vs TAU (approved psychotherapy of manualised CBT with 1 participant also receiving family therapy)individual sessions, no info. frequency; Clinic setting

n= 38 (22+16),n male= ACT 4(18%), TAU 7(44%)Age 12 -18 yrs, mean 14.9, sd 2.55

IndigenousAustralian 1 (2.6)

Heffner et al., 2002 - USA Anorexia Case Study ACT (no comparison group)18x individual sessions; Clinic setting

n= 1, male=0 (0%)Age 15 yrs

white 1 (100)

Livheim et al., (2015) - Australia

mild - moderate depression

Between Group

ACT vs TAU (12 weeks monitoring by School Counsellor)ACT 8x group sessions; School setting

n= 66 (40+26), n male= ACT 8(12%), TAU 0 (0%)Age 12 -17yrs, mean 14.6, sd 1.03

no info.

Table 3 continued

Overview of Included Studies

Study Difficulty Design Treatment Participants Ethnicity n (%)

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Livheim et al., (2015) - Sweden

mild – moderatestress

RCT ACT vs TAU (monitoring by School Nurse)ACT 6x 90min group sessions, TAU half received 2-8 individual counselling sessions; School setting

n= 32 (15+17), n male= 9 (28%)Age 14-15yrs, no info. mean or sd

no info.

Luciano et al., 2011 - Spain

at risk of impulsivity / emotional difficulties

Between & Within Group

Defusion Protocol 1 (D1) vs Defusion Protocol 2 (D2)5x60min group sessions; School setting

n= 15, D1 (low risk1)=4, D2 (low risk1)=5, D2 (high risk2)=6, n male= 7 (47%)Age 12-15yrs, mean 13.66, sd 0.9;

no info.

Murrell et al., 2015 - USA ADHD + Comorbid disorders

Within Group ACT (no comparison group)8x60 group sessions; School setting

n=9, n male= 4 (44%)Age 11-15yrs, mean 11.78, sd 1.3;

US African (89), Hispanic (11)

Petts et al., 2017 - USA Depression Within Group Motivational Interviewing Assessment (MIA) + ACT (no comparison group); MIA 3 individual sessions + up to 12 ACT individual sessions; School setting

n=11, n male= 4 (27%)Age 14-18yrs, mean 15.82, sd 1.40

US African 7 (47), Mixed 6 (40), US EU 2 (7)

Schneider & Arch, 2017 - USA

Misophonia Case Study ACT + DBT (no comparison group)10x50min individual sessions; Clinic setting

n=1, n male = 1 (100%)Age 17yrs

no info.

Swain et al., 2015b (adol. sample of Hancock et al., 2016) - Australia

Anxiety RCT ACT vs CBT vs waitlist ctrl10x60min group sessions; Clinic setting

n=49, (ACT=16, CBT=10, waitlist=23), n male= 18 (37%)Age 12-17yrs, mean 13.8 , sd 1.4

white 33 (67.3), Mid East 7 (14.3), EU 4 (8.2), Asian 5 (10.2)

Theodore-Oklota et al., 2014 - USA

Relational Aggression Between Group

ACT vs waitlist ctrl3x48min whole class sessions; School setting

n=210 (105+105), n male= 66%Age mean 12.45, sd 0.51

white (67.6), no info. (23.4), other (10)

Timko et al., 2015(inclusive of Merwin et al., 2013 data) - USA

Anorexia Within Group / Open Trial

Acceptance Based Family Therapy (no comparison group); 12-16x 90min individual + 4-6x 60min family sessions; Clinic setting

n=47 families, n male= 6 (13%)Age 12-18yrs, mean 14.02, sd 1.58

white 43 (91)

Van der Gucht et al., 2017 - Belgium

preventative universal cluster RCT teacher delivered ACT vs no treatment ctrl4x120min whole class sessions; School setting

n=586 (308+308) , n male= 47%Age 14-21yrs, mean 17, sd 0.66

no info.

Woidneck et al., 2014 - USA

Post Traumatic Stress Case Series ACT vs baseline ctrl10x60min individual sessions; Clinic & Inpatient settings

n=10, n male= 2 (29%)Age 12-17yrs, mean 14.57, sd 1.62

no info.

Note. ACT= Acceptance and Commitment Therapy; adol.= adolescent; ctrl=control group; DBT= Dialectical Behavioural Therapy; indiv=individual; no info.= no information provided; OCD = obsessive compulsive disorder; RCT= Randomised control trail; TAU= Treatment as usual. 1Low Risk – <6 problem behaviours; 2High Risk 6+ problem behaviours; EU= European; Mid East= Middle Eastern; S. Asian= South Asian; US= American

25

intervention. Despite the searches having no limit on publication date, all studies were

recent, with the earliest published in 2002 (Heffner, Sperry, Eifert & Detweiler, 2002). The 19

remaining studies were published in the last seven years since 2011, and 14 of these in the

last 4 years.

Methodological Quality Across Studies

Table 4 details the breakdown of POSMRF methodological ratings for each item. The

following paragraphs highlight common methodological issues occurring across studies;

table 5 details methodological weaknesses specific to each study.

Design of studies.

The most striking factor across the adolescent studies was that 15 out of 20 studies

described themselves as ‘pilot’, ‘feasibility’ or ‘preliminary’ research (Armstrong Morrison &

Twohig, 2013; Burckhard et al., 2016; Burckhard, Manicavasagar, Batterham, Pavlovic &

Shand, 2017; Franklin, Best, Wilson, Loew & Compton, 2011; Gomez et al., 2014; Hayes et

al., 2011; Livheim et al., 2015; Luciano et al., 2011; Murrell, Steinberg, Connally, Hulsey &

Hogan, 2016; Petts, Duenas & Gaynor, 2017; Swain et al., 2015b; Theodore-Oklota, Orsillo,

Lee & Vernig, 2014; Timko et al., 2015; Woidneck Morrison & Twohig, 2014). Of the five that

did not, three were case illustrations (Fine et al., 2012; Heffner et al., 2002; Schneider &

Arch, 2017).

Four studies were randomised controlled trials (RCT; Burckhard et al., 2016; Hayes et al.,

2011; the Swedish study within Livheim et al., 2015; Swain et al., 2015b) and one

cluster RCT (Van der Gucht et al., 2017). Another five adopted a between group

26

design, (Azadeh, Kazemi-Zahrani & Besharat, 2016; Burckhard et al., 2017; Franklin et

al., 2011; the Australian study within Livheim et al., 2015; Theodore-Oklota et al.,

2014) and Luciano et al., (2011) used both a within and between group design,

however numbers were small across groups. The remaining nine studies had no

comparison group. This comprised of 3 within group designs (Murrell et al., 2016;

Petts et al., 2017; Timko et al., 2015), and six case series; of which three used a

multiple baseline control, (Armstrong et al., 2013; Gomez et al., 2014; Woidneck et

al., 2014) and 3 were case illustrations totalling 4 participants between them (Fine et

al., 2016; Heffner et al., 2002; Schneider & Arch, 2017).

Over half the studies (n=11) had a control group. Comparison included two studies

comparing ACT with another evidence based therapy, namely Cognitive Behavioural Therapy

(CBT) and one of these also included a wait list control (WLC) comparison (Hayes et al., 2011;

Swain et al., 2015b). Two preventative school studies used treatment as usual (TAU) of

pastoral care curriculum, which had identical hours of input to the intervention (Burckhard

et al., 2016; 2017). However other comparison groups were less methodologically robust;

the two Livheim et al (2015) Australian and Swedish studies used treatment as usual (TAU)

controls with significantly fewer treatment hours to the ACT intervention, another two used

a no treatment comparison group (Azadeh et al., 2016; Van der Gucht et al., 2017) and one

included a wait-list comparison group (Theodore-Oklota et al., 2014). The final two

comparison groups were expansions of the same treatment; one was a more advanced

Defusion protocol (Luciano et al., 2011) and habit reversal training (HRT) without ACT

(Franklin et al., 2011).

27

Diversity of Sample.

Surprisingly none of the studies used a UK sample. The majority of studies were from the

USA (n=10, 50%; Armstrong et al., 2013; Fine et al., 2012; Franklin et al., 2011; Heffner et al.,

2002; Murrell et al., 2016; Petts et al., 2017; Schneider & Arch, 2017;Theodore-Oklota et al.,

2014; Timko et al., 2015; Woidneck et al., 2014), followed by Australia (n=5, 25%; Burckhard

et al., 2016; 2017; Hayes et al., 2011; Livheim et al., 2015; Swain et al., 2015b), Spain (n=2,

10%; Gomez et al., 2014; Luciano et al., 2011), and one from Iran, Sweden and Belgium (5%

each; Azadeh et al., 2016; Livheim et al., 2015;Van der Gucht et al., 2017). Unfortunately

participant ethnicity was only reported in under half of the studies (n=9; Fine et al., 2012;

Franklin et al., 2011; Hayes et al., 2011; Heffner et al., 2002; Murrell et al., 2016; Petts et al.,

2017; Swain et al., 2015b; Theodore-Oklota et al., 2014; Timko et al., 2015).

Setting, Target Problem and Reliability of Diagnosis.

The studies targeted a wide breadth of difficulties. Eleven interventions were delivered in

school settings and nine in clinical settings. Difficulties varied in type, severity and chronicity;

the setting influenced the reliability of the diagnosis.

The nine studies delivered in clinical settings targeted mental health difficulties; namely,

anxiety, misophonia, OCD, post-traumatic stress, trichotillomania, Tourette’s syndrome,

depression and anorexia nervosa (Armstrong et al., 2013; Azadeh et al., 2016; Fine et al.,

2012; Franklin et al., 2011; Hayes et al., 2011; Heffner et al., 2002; Schneider & Arch, 2017;

Swain et al., 2015b; Timko et al., 2015; Woidneck et al., 2014). Heffner et al.’s (2002)

anorexia case study stated the diagnosis but did not describe using a recognised diagnostic

classification system, however all other clinical studies used structured interviews which

28

follow DSM-IV, DSM-V or ICD-10, to verify diagnosis (American Psychiatric Association, 2000;

2013; World Health Organisation, 1992).

The eleven remaining school studies were less rigorous with diagnosis (Burckhard et al.,

2016; Burckhard et al., 2017; Gomez et al., 2014; Livheim et al., 2015; Luciano et al., 2011;

Murrell et al., 2016; Petts et al., 2017; Theodore-Oklota et al., 2014; Van der Gucht et al.,

2017). Two did report using a recognised diagnostic assessment; the first used a structured

clinical interview to assess for depression according to DSM-IV (American Psychiatric

Association, 2000; Petts et al., 2017). The second used DSM-V criteria to assess social

anxiety, however did not report the training or experience of the assessor or how this

assessment was carried out e.g. by structured interview (American Psychiatric Association,

2013; Azadeh et al., 2016). All other school studies did not report assessment of diagnosis

against recognised criteria. Three studies included adolescents with mild to moderate

symptoms of stress, depression, impulsivity/emotional difficulties, and thus likely below

diagnostic thresholds (Livheim et al., 2015; Luciano et al., 2011). Two studies which included

adolescents with ADHD and comorbid learning difficulties (Murrell et al., 2015), and

treatment resistant conduct disorder and impulsivity (Gomez et al., 2014), both failed to

report a diagnostic assessment. The final four school studies delivered a universal

intervention, rather than targeting a subsample with pre-existing difficulties. These were

aimed at preventing mental health difficulties, (Burckhardt et al., 2016; Burckhardt et al.,

2017; Van der Gucht et al., 2017) and relational aggression (Theodore-Oklota et al., 2014).

The POSMRF item, ‘reliability of diagnosis’ had a low mean score of 0.55 (SD 0.69) out of 2

across all studies. The overall score was bought down by the school studies, and lack of

29

Table 4

Psychotherapy Outcome Study Methodological Rating Form Ratings

POSMRF Item Arm

stro

ng e

t al.,

201

3

Azad

eh e

t al.,

201

6

Burc

khar

dt e

t al.,

201

6

Burc

khar

dt e

t al.,

201

7

Fine

et a

l., 2

012

Fran

klin

et a

l., 2

011

Gom

ez e

t al.,

201

4

Heffn

er e

t al.,

200

2

Haye

s et a

l., 2

011

Livh

eim

et a

l., (2

015)

Aus

Livh

eim

et a

l., (2

015)

Sw

e

Luci

ano

et a

l., 2

011

Mur

rell

et a

l., 2

015

Pett

s et a

l., 2

017

Schn

eide

r & A

rch,

201

7

Swai

n et

al.,

201

5b

Theo

dore

-Okl

ota

et a

l., 2

014

Tim

ko e

t al.,

201

5

Van

der G

ucht

et a

l., 2

017

Woi

dnec

k et

al.,

201

4

Mean (SD)

1. Clarity of sample description 2 1 1 1 0 2 0 0 1 1 1 0 1 2 2 1 1 1 1 2 1.05 2. Severity/chronicity of the disorder 1 1 0 0 1 2 2 1 1 0 0 0 1 0 1 1 0 1 0 1 0.70 3. Representativeness of the sample 1 1 1 1 0 2 2 0 1 0 0 0 2 1 0 1 2 1 2 1 0.95

4. Reliability of the diagnosis in question 1 0 0 0 1 1 0 0 1 0 0 0 0 2 1 2 0 1 0 1 0.55 5. Specificity of outcome measures 2 1 1 1 2 2 2 2 2 2 1 1 1 2 2 2 2 2 2 2 1.70

6. Reliability and validity of outcome measures 2 1 2 2 1 1 1 1 2 2 1 1 1 2 1 2 1 1 2 2 1.45 7. Use of blind evaluators 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0.15

8. Assessor training 0 0 0 0 0 1 0 0 0 0 0 0 0 2 0 2 0 1 0 1 0.35 9. Assignment to treatment 0 1 1 0 0 0 0 0 1 1 1 0 0 0 0 1 0 0 1 0 0.35

10. Design 0 0 1 1 0 0 0 0 2 0 1 0 0 0 0 2 1 0 0 0 0.40 11. Power analysis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0.05

12. Assessment points 1 0 0 1 0 1 1 0 1 0 0 1 0 1 1 1 0 1 2 1 0.65 13. Manualized, replicable, specific treatment 1 1 0 0 1 2 2 0 1 1 1 2 1 1 1 2 2 1 1 1 1.10

14. Number of therapists 0 0 0 0 0 1 0 0 1 1 1 0 0 1 0 1 1 1 2 0 0.50 15. Therapist training/experience 0 0 2 1 0 1 1 0 1 1 0 0 2 1 0 2 0 0 1 0 0.65

16. Checks for treatment adherence 1 0 1 0 0 0 0 0 0 0 0 2 0 1 0 2 0 1 0 1 0.45 17. Checks for therapist competence 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0.20

18. Control of concomitant treatments (e.g. 1 2 0 0 0 1 0 0 0 0 2 0 0 2 0 1 0 1 0 0 0.50 19. Handling of attrition 2 2 2 2 0 2 2 2 0 1 1 2 0 1 0 2 0 1 1 0 1.15

20. Statistical analyses and presentation of results 1 2 2 2 0 0 1 0 2 2 2 1 1 2 0 2 2 2 2 1 1.35 21. Clinical significance 0 0 1 0 0 0 0 0 2 0 0 0 1 2 0 0 0 0 0 0 0.30

22. Equality of therapy hours (for non-WLC designs n/a n/a 2 2 n/a n/a n/a n/a 0 0 0 2 n/a n/a n/a 2 n/a n/a n/a n/a 1.14 TOTAL 17 13 17 14 6 20 14 6 19 12 12 12 11 24 9 33 12 16 17 15 14.95

(6.13)

30

31

inter-rater reliability assessment of diagnosis in all but two studies (Petts et al., 2017; Swain

et al., 2015b).

Chronicity and Complexity.

Chronicity of difficulties was only reported in 4 of the 20 studies, all of which had a small

sample size of between 1 and 13 participants. Of these, only two included participants with

chronic difficulties lasting at least 12 months (Franklin et al., 2011; Gomez et al., 2014). The

others were under 12 months and one participant had symptoms for only 1 month (Fine et

al., 2012; Heffner et al., 2002). Proportion of comorbid difficulties were only reported in 6 of

the studies, which again consisted of small sample sizes (n≤13).

Outcome measures.

Primary outcome measures were disorder specific across all studies; although the

preventative studies (Burckhardt et al., 2016; 2017; Van der Gurcht et al., 2017), used more

global measures of multiple common mental health difficulties and wellbeing. Including, the

Flourishing Scale (FS; Diener et al., 2010) and the World Health Organisation Quality of Life

Questionnaire (WHOQoL-Bref; Skevington, Lotfy & O’Connell, 2004). The measures used

across other studies varied on the difficulty being addressed, however some measures

occurred in multiple studies, including three studies which used the Anxiety Disorders

Interview Schedule, Child Version (ADIS-CV; Albano and Silverman, 1996), a semi-structured

interview which provides a Clinical Severity Rating (Armstrong et al., 2013; Franklin et al.,

2011; Swain et al., 2015b). Two studies (Luciano et al., 2011; Murrell et al., 2016) used the

Behaviour Assessment for Children, including a Spanish version (BASC-2, Reynolds and

Kamphaus, 2004a; 2004b). A further two studies (Hayes et al., 2011; Livheim et al., 2015)

32

included the Reynolds Adolescent Depression Scale-2 (RADS-2; Reynolds, 2010).

ACT process measures were used in 13 of the studies (Armstrong et al., 2013; Azadeh et al.,

2016; Gomez et al., 2014; Livheim et al., 2015; Luciano et al., 2011; Murrell et al., 2016; Petts

et al., 2017; Swain et al., 2015b; Theodore-Oklota et al., 2014; Timko et al., 2015; Van der

Gucht et al., 2017; Woidneck et al., 2014). Including, measures of mindfulness e.g. Mindful

Attention Awareness Scale (MAAS; Brown and Ryan 2003); experiential avoidance e.g.

Acceptance and Fusion Questionnaire for Youths (AFQ-Y; Greco, Baer & Lambert, 2008) and

values e.g. Valued Living Questionnaire (VLQ; Wilson, Sandoz, Kitchens & Roberts, 2010).

Choice of outcome measures was a relative strength across studies; ‘Specificity of outcome

measures’ was the highest rated POSMRF item (mean 1.70) and ‘Reliability and validity of

outcome measures’ the second highest (mean 1.45). The majority (70%) of the studies used

a primary outcome measure specifically designed for young people or validated with a youth

sample (Armstrong et al., 2013; Burckhard et al., 2016; 2017; Franklin et al., 2011; Hayes et

al., 2011; Australian study of Livheim et al., 2015; Luciano et al., 2011; Murrell et al., 2016;

Petts et al., 2017; Swain et al., 2015b; Theodore-Oklota et al., 2014; Timko et al., 2015; Van

der Gucht et al., 2017; Woidneck et al., 2014;), and all studies used at least one outcome

measure with adequate reliability and validity with a youth sample.

One issue that presided over studies from non-English speaking countries was the limited

availability of outcome measures validated within a youth sample in the local language. Van

der Gucht et al., (2017) used a validated Dutch version of the Youth Self Report (YSR; de

33

Groot et al. 1996; Verhulst et al. 1997). Whilst Gomez et al., (2014) used behavioural

observations of students as their primary outcome, and Spanish version of the Self-Control

Schedule (SCS; Capafóns & Barreto, 1989). Other studies translated and back-translated

existing outcome measures (Swedish study of Livheim et al., 2015; Luciano et al., 2011); this

is problematic as the reliability of the translation cannot be verified and the validity and

reliability of the translated version was available. For example, Luciano et al., (2011) created

their own Spanish ACT based measure that combined elements of the AFQ-Y (Greco et al.,

2008) and a mindfulness measure, however again this was not validated prior to the study.

Of the 11 studies which used comparison groups, only two studies used evaluators that were

blinded to treatment conditions (Franklin et al., 2011; Swain et al., 2015b) and only Swain et

al., (2015b) assessed for inter-rater reliability. Resulting in a mean POSMRF rating of 0.15 for

‘use of blind evaluators’. Furthermore across all studies only 5 reported the use of trained

assessors for outcomes (mean POSMRF 0.35; Franklin et al., 2011; Petts et al., 2017; Swain et

al., 2015b; Timko et al., 2015; Woidneck et al., 2014), this was largely due to the self-report

nature of the outcome measures.

Power, Data Points and Follow Up.

Power calculations were reported and followed in only one of the 20 studies (Swain et al.,

2015b); this is noteworthy as the papers include 5 RCTs and resulted in the poorest POSMRF

rating (mean 0.05). Over a third of the studies did not include a follow up assessment

(Azadeh et al., 2016; Burckhard et al., 2016; 2017; Fine et al., 2012; Heffner et al., 2002;

Livheim et al., 2015; Murrell et al., 2016) and of the 12 studies that did, only one reported

longer term follow up over 12 months (Petts et al., 2017) follow up in the remaining studies

34

ranged between 1 and 6 months.

35

Table 5

Methodological Weaknesses Across StudiesStudy WeaknessesArmstrong et al., 2013

- small sample n=3- no inferential statistics (due to small n)- one therapist who also conducted assessments- no comparison group

Azadeh et al., 2016

- many typos throughout article including decimal points replaced by "/"- social anxiety outcome measure was used only as screening tool only, not outcome- unclear if outcome measures were translated for participants- little information re protocol- no follow up

Burckhardt et al., 2016

- no blinding to treatment / control condition- many potentially confounding variables e.g. extra-curricular activities, school counsellor support,

which were not controlled for in the study- no follow up or use of ACT process measures- attendance at intervention or control reasons for drop-out were not collected- not possible to separate impact of the ACT and PP aspects of the intervention- no fidelity assessment of the PP or pastoral care curriculums- not adolescent/child specific outcome measures and all self-report

Burckhardt et al., 2017

- sample lacks representativeness – independent school affluent and high academic ability- unable to differentiate impact of psychologist-led workshop and teacher-led practical- did not use ACT process measures- no competence assessment of teachers or psychologist- Substantial attrition in control group due to student absence

Fine et al., 2012 - n=2 selected from clinical setting but no rationale for why these two selected- did not use ACT process measures- no empirical analysis

Franklin et al., 2011

- no random allocation to group, HRT group allocation started before HRT+ACT- no means and SDs only graphical data of means- lots of data seems to have been gathered but not all reported- did not use ACT process measures

Gomez et al., 2014

- no randomisation or comparison group- opportunity sample- follow up does not include validated outcome measures (only behavioural observations)- therapist competence and adherence to protocol not assessed- some data collected was not reported (between pre and post time points)- not possible to isolate effects of intervention from other factors

Hayes et al., 2011

- possible cross-contamination of therapy models (ACT training delivered to all therapists, therapists delivered both ACT +TAU (CBT))

- some treatment overlap - BA & goals (not ACT)- uneven groups, therapy hours- underpowered / no power analysis and low numbers of follow up data- did not use ACT process measures

Heffner et al., 2002

- N=1 – case illustration only- CBT and other Family involvement were in addition to ACT treatment- No comparison group- No inclusion / exclusion criteria- did not use ACT process measures

Table 5 continued.

36

Methodological Weaknesses Across StudiesStudy WeaknessesMurrell et al., 2015

- EA Not possible to explore- teachers and parents both did not completing measures- student self-report only

Livheim et al., 2015

- no follow up- Majority female participants- TAU comparison – not equivalent treatment hours and individual rather than group- Two versions of AFQ (Aus= 8 items; Swed=17 items)Swedish Study:- Not representative sample; affluent and high academic attainment- ACT sessions had to be condensed into 6 weeks, compared to 8.- Outcome measures were translated and back-translated (implications for validity)

Luciano et al., 2011

- small n- no comparison group for high-risk participants- no opportunity to incorporate planned experimental tasks of psychological flexibility and

experiential avoidance.- AFQ-S created for the study (combination of …) and not validated.

Petts et al., 2017 - Participants received a different number of treatment sessions; some received 12 sessions, whilst others had 6. This was due to late enrolment to the study in the academic year.

- It is difficult to differentiate the impact of ACT compared with the Motivational Interviewing component.

- Poor attendanceSchneider & Arch, 2017

- N=1, lacks generalisability- No reliability data for primary outcome measures and are not validated with youth- Clients scores began in moderate range – needs replication with more severe clinical group- did not use ACT process measures

Swain et al., 2015b (Hancock et al., 2016)

- WLC not included in3 month follow up data- Main effects analysed with younger children- Limited available data for adolescent sub-sample

Timko et al., 2015 (Merwin et al., 2013)

- no comparison group- high dropout rates- not checks of therapist competence

Theodore-Oklota et al., 2014

- No random assignment to treatment, due to offering on whole classroom basis- Higher rates of physical aggression at baseline reported in waitlist control group- Parts of intervention may have been shared with waitlist control group through discussions

amongst students, as both intervention and control groups attended the same school- Study relied on student self-report, may be poor reporters of peer aggression.- Low alphas on a problem-solving subscale, limiting interpretation.

Van der Gurcht et al., 2017

- fidelity and teacher competence in delivery of in intervention is not measured- effect of teacher and school are not analysed- no control of treatment contamination (e.g. people receiving therapeutic treatment)- large variation in post timeframe (1-8 weeks) thus immediate post treatment effect was not

possible.Woidneck et al., 2014

- almost half sample from inpatient anorexia ward, receiving individual, group and family therapy alongside intervention. The effect of this is not accounted for in the analysis

- high attrition 30%- mixed sample of inpatient (with comorbid Anorexia diagnosis) and community

37

Intervention Delivery and Checks.

All but one (Gomez et al., 2014) of the eleven school studies delivered group or whole class

interventions, and only one of the clinical study used a group treatment delivery, which was

an RCT for different anxiety disorders (Swain et al., 2015b). One clinical study delivered ACT

as a family intervention in addition to individual sessions (Timko et al., 2015). All except

three studies used interventions based on publically available treatment manuals (Burckhard

et al., 2016; 2017; Heffner et al., 2002), allowing for future replication of treatment, which

was a further methodological strength across the studies.

Checks for adherence to the treatment protocol and therapist competence were sparse

across the literature, with only 7 studies making any attempt to evaluate adherence to

treatment (POSMRF means 0.45; Armstrong et al., 2013; Burckhard et al., 2016; Luciano et

al., 2011; Petts et al., 2017; Swain et al., 2015b; Timko et al., 2015; Woidneck et al., 2014)

and four checking therapist competence (POSMRF mean 0.20; Armstrong et al., 2013; Petts

et al., 2017; Swain et al., 2015b; Woidneck et al., 2014). Similarly, clinical experience of the

therapist was not reported in 5 studies (Azadeh et al., 2016; Armstrong et al., 2013, Fine et

al., 2012; Luciano et al., 2011; Schneider & Arch, 2017). Student therapists were used in 4

studies (Livheim et al., 2015 Swedish; Theodore-Oklota et al., 2014; Heffner et al., 2002;

Woidneck et al., 2014) and two preventative school studies used teachers to deliver all or

part of the treatment (Burckhardt et al., 2017; Van der Gucht et al., 2017). Of these, only one

study which used a student therapist checked therapist competence and adherence to the

protocol (Woidneck et al., 2014).

38

Examination of Outcomes and ACT Processes

In total, effect size (ES) comparisons of primary outcome measures were possible in half of

the studies (see table 6). Of these, two had no comparison group meaning uncontrolled ES

was calculated (Petts et al., 2017; Timko et al., 2015), whilst controlled ES using Morris’s

(2008) recommended formula was calculated on the others. Additionally 8 studies used ACT

process measures with a large enough sample for ES calculations and three studies did not

include ACT process measures (Burckhardt et al., 2016; 2017; Hayes et al., 2011).

Unfortunately calculating ES for Swain et al.’s (2015b) study was not possible, as mean and

standard deviation data was not provided on any outcomes from their subsample of

adolescents. This was disappointing as this was the only study to use a power calculation;

only cautionary interpretations of the ES’s can be made for all other studies as they lack

power. Table 6 shows ES across studies.

Effect Sizes on Primary Outcome Measures.

Moderate to very large controlled and uncontrolled effect sizes were found on primary

outcome measures across studies using ACT interventions in social anxiety (Azadeh et al.,

2016), depression (Hayes et al., 2011; Livheim et al., 2015; Petts et al., 2017), stress (Livheim

et al., 2015), and anorexia, including measures of parental observations and adolescent self-

report (Timko et al., 2015). Four studies showed smaller or minimal effects, interestingly

they all delivered universal preventative ACT interventions in schools. Burchardt et al., 2016

delivered an ACT plus positive psychology (PP) protocol targeting depression, they found a

moderate ES (d=-0.44) for the ACT+PP intervention in a subsample of students with raised

39

depression scores, but ES showed minimal gains for the ACT+PP compared to pastoral care

curriculum on a wellbeing measure across the whole school sample (d=0.19). The same

research group piloted a purely ACT protocol to a smaller school sample (n=48) with more

promising small to moderate effects, increasing at follow-up compared to TAU, on measures

of depression, anxiety, and stress (d=-0.44 to -0.59) and wellbeing (d=0.2 to 0.3; Burchardt et

al., 2017). Two school studies showed no preferential effect for the ACT intervention

compared to control. The first was a teacher delivered intervention (Van der Gucht et al.,

2017); the authors concluded that the lack of effect could be due to the brevity of the

intervention and the delivery, suggesting that ACT should be delivered by professionally

trained therapists. The final study used ACT to address relational aggression, although they

did not find main effect for the intervention compared to control, they did note a significant

association between experiential avoidance and, being both a victim or perpetrators of

relational and physical aggression (Theodore-Oklota et al., 2014).

Effect Sizes on ACT Process Measures.

Three studies found moderate to very large ESs compared to control group of ACT processes

including mindfulness, acceptance and committed action, and experiential avoidance

(Azadeh et al., 2016; Livheim et al., 2015). Petts et al., (2017) found moderate uncontrolled

pre to post ES reductions in experiential avoidance. Timko et al., (2015) showed small ES’s

reductions on adolescent experiential avoidance ratings (d=-0.48 - -0.35) whereas maternal

and paternal acceptance and action ratings showed little impact at post, and maternal

ratings showed small deterioration at follow up (d=0.29). As might be expected, the two of

40

Table 6

Effect sizes of primary outcome measures and ACT process measures

Controlled Effect Size d Uncontrolled Effect Size d

Study Measuring Measure C Post FU Pre-post Pre-FU

Primary Outcomes

Azadeh et al., 2016 Int. Probs IIP-60 a -1.43***

Burckhard et al., 2016 Dep & Anxc DASS-21 a -0.57**

Wellbeing FS a 0.19

Burckhard et al., 2017 Dep & Anx DASS-21 a -0.44* -0.59**

Wellbeing FS a 0.20* 0.31*

Hayes et al., 2011 Dep RADS-2 a -0.86*** -7.82***

Livheim et al., 2015 Aus Dep RADS-2 a -3.82***

Livheim et al., 2015 Swe Stress PSS a -4.03***

Petts et al., 2017 (IIT) Dep CDSR a -3.53 ***

Theodore-Oklota et al., 2014 Rel. Agg. PEQ-R-RA a 0.05

Rel. Victim. SEQ-RV a -0.10

Timko et al., 2015 b Anorexia EDE a -0.62**

Body mass BMI o 1.42***

Anorexia ABOS m -1.35*** -1.77***

Anorexia ABOS f -1.34*** -1.48***

Van der Gucht et al., 2017 Dep YSR-Aff a -0.05 0.06

Anx YSR-Anx a -0.14 -0.04

ACT Process Measures

Azadeh et al., 2016 Psych Flex. AAQ-II a -0.81***

Livheim et al., 2015 Aus EA AFQ-Y a -2.70***

Livheim et al., 2015 Swe EA AFQ-Y a -0.71**

Mindfulness MAAS 2.24***

Petts et al., 2017 (IIT) EA AFQ-Y a -0.74**

Theodore-Oklota et al., 2014 EA AFQ-Y a -0.04

Timko et al., 2015 b EA AFQ-Y a -0.48* -0.35*

Psych Flex. AAQ-II m -0.03 0.29*

Psych Flex. AAQ-II f -0.11 0.01

Van der Gucht et al., 2017 AFQ-Y a -0.03 0.15

Note. C= Completed by; a adolescent sample of Hancock et al., 2016, b inclusive of data from Merwin et al., cfor subgroup with high depression and anxiety scores at baseline; Int. Probs= interpersonal problems Obsessive compulsive disorder; Dep= depression; Anx= anxiety; An=anorexia; EA= experiential avoidance, Rel.= Relational; Agg.= Aggression; Victim.= Victimisation; Psych Flex.= Psychological Flexibility; ABOS= Anorectic Behaviour Observation Scale (Vandereycken, 1992), BMI= Body Mass Index (Percentile), CDSR= Children's Depression Rating Scale-Revised (Poznanski & Mokros, 1996), DASS-21= Depression anxiety and stress scale — short form (Lovibond & Lovibond, 1995), EDE= Eating Disorder Examination - Global Score (Cooper & Fairburn, 1987), FS= Flourishing scale (Diener et al., 2010), IIP-60= Inventory of Interpersonal Problems (Besharat, 2010), PEQ-R-RA= Relational aggression subscale (10 items) of Revised Peer Experiences Questionnaire (Prinstein et al., 2001), PSS= The Perceived Stress Scale (Cohen and Janicki-Deverts, 2012), RADS-2= Reynolds Adolescent Depression Scale-2 (Reynolds, 2010), SEQ-RV= Relational Victimisation subscale (11 items) of Revised-Social Experiences Questionnaire (Crick & Grotpeter,1996), YSR-Aff= Youth Self Report - Affective Problems (Achenbach, 1991), YSR-Anx= Youth Self Report - Anxiety Problems (Achenbach, 1991); AAQ-II= Acceptance and Action Questionnaire-II (Bond et al., 2011); AFQ-Y= Avoidance and Fusion Questionnaire for Youth (Greco et al., 2008); MAAS= Mindful Attention Awareness Scale (Brown & Ryan 2003); CAMM= Child and Adolescent Mindfulness Measure (Ciarrochi, Kashdan, Leeson, Heaven & Jordan, 2011); a=adolescent, m=mothers, f=father, o=other; ***large effect size; **moderate effect size

41

the universal preventative school interventions which showed no effect on primary

outcomes also found no effect on ACT process outcomes (Theodore-Oklota et al., 2014; Van

der Gucht et al., 2017).

Small n studies: Summary of Outcomes and ACT Processes

Table 7 shows a summary of outcomes and ACT process results across small n studies. In

summary, these underpowered studies mostly had positive effects on outcomes, for a range

of difficulties with many participants making clinically significant change (Armstrong et al.,

2013; Fine et al., 2012; Franklin et al., 2011; Gomez et al., 2014; Heffner et al., 2002; Luciano

et al., 2011; Murrell et al., 2015; Schneider & Arch, 2017; Swain et al., 2015; Woidneck et al.,

2014). Luciano et al., (2011) tested two defusion models and found better results for the

defusion with added hierarchical framing produced better outcomes. The weakest findings

were from Murrell et al., (2015) who applied ACT to ADHD with comorbid learning disorders,

however they encountered a number of feasibility issues with delivering the intervention in

a school setting. Results were mixed, with almost half of the sample showing deterioration.

In addition to Swain et al, (2015), five of the 9 small n studies, used ACT process measures

with mixed findings. Similar methodological issues were found by Murrell et al., (2015) as

pre experiential avoidance data was not reliable because participants did not understand the

questions. Positive change in psychological flexibility for youth with post traumatic stress

was noted by Woidneck et al., (2014), and for half of the sample with conduct disorder in

Gomez et al.’s, (2014) study. Luciano et al., (2011) found changes on ACT process measures

in the low risk group, however these were not evident in the high-risk group. Finally

42

Table 7

Summary of Main Outcomes and ACT Process Outcomes Across Small N Studies

Study Difficulty

N analy-sed Outcomes

Armstrong et al., 2013

OCD 3 Frequency of compulsions decreased 40% across all 3 pts from pre-post and 43.8% pre-FU. CY-BOCS – 1 pt began in non-clinical range, 2pts baseline scores in clinical for moved to non-clinical range at post for 1pt and FU for 1pt. AFQ-Y – 2pts showed no change, 1pt showed reductions at post but were not maintained at FU

Fine et al., 2012

Tricho-tillamania

2 Both pts showed pre-post reductions on MIST-C (focussed and automatic pulling) and TSC (pulling severity and distress). 1pt relapsed but improved with a booster session

Franklin et al., 2011

Tourette Syndrome

13(6, 7)

YGTSS (rated by independent evaluator) score reduce from clinical to non-clinical ranges in both HRT+ACT and HRT alone groups with HRT=ACT+HRT. CGI (rated by independent evaluator) HRT>ACT+HRT. Authors attributes to therapists level of experience in ACT

Gomez et al., 2014

Conduct Disorder and Impulsivity

5 significant pre-post reductions in impulsivity (EMIC), significant pre-post improvements in self control (SCS), Number of disruptive behaviours almost 0 at post for all pts, Increases in desirable behaviours at post. AAQ-II – 3/5 pts showed improvements in psychological flexibility

Heffner et al., 2002

Anorexia 1 EDI-2 moved from clinical to non-clinical range on 2 subscales, ‘drive for thinness’ and ‘ineffectiveness’. No change, remain in clinical range for ‘body dissatisfaction’

Luciano et al., 2011

At risk of impulsivity and emotional difficulties

15(4, 5, 6)

Comparison of defusion 1 and 2 protocols in low risk groups: D2>D1, D2= significantly fewer problem behaviours, less experiential avoidance (AFQ-S), increased acceptance (KIMS). High risk received only D2 – the group showed significant pre-post and pre-FU reductions in number of problem behaviours, 1/6 pt did not maintain this at FU. Acceptance (KIMS) increased at post but not maintained at FU, experiential avoidance (AFQ-S) showed no change.

Murrell et al., 2015

ADHD + Comorbid disorders

7 ESI – 2 pts reliable improvement; 2 pts no change, 3 pts reliable deterioration. AFQ-Y – unreliable pre scores. BE-Values – 2 pts reliable improvement; 1 pt reliable deterioration

Schneider & Arch, 2017

Miso-phonia

1 A-MISO - moved from moderate to mild symptoms post, with further decreases in mild range at follow up

Swain et al., 2015

Anxiety 4916 ACT10 CBT23 WLC

AFQ-Y – both ACT and CBT conditions showed increases at post and ACT showed further significant gains between post and 3-month follow-up, CAMM-mindful observing subscale – ACT and wait list groups had greater mindful observing at post compared to CBT group, VLQ – non significant across groupsMediation analysis found that the hexaflex mediated the relationship between anxiety ratings for ACT but not CBT, however the effect was bolstered by AFQ-Y.

Woidneck et al., 2014

Post Traumatic Stress

7 CAPS-CA – 6/7 pt moved out of severe range at post; 4x sub clinical and 2x mild, the other withdrew and was mild at FU. CPSS – 4/7 sub clinical at post, of 3 pts still in clinical range at post, 2x sub clinical at FU, 1x near sub-clinical at FU. AFQ-Y – 6/7 pts showed improvements in psychological flexibility which coincided with reduced PTS symptoms.

notes: pt(s)= participant(s); FU= Follow-up; LR= Low Risk – <6 problem behaviours; HR= High Risk 6+ problem behaviours; D1= Defusion protocol 1; D2= Defusion protocol 2; A-MISO= Amsterdam Misophonia Scale (Schröder, Vulink & Denys, 2013); CAPS-CA= Clinician Administered PTSD Scale for Children and Adolescents (Newman et al., 2004); CGI= Clinical Global Impression-Improvement (Guy, 1979); CPSS- Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001); CY-BOCS= Children’s Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997); EDI-2= Eating Disorder Inventory (Garner, 1991); EMIC= Magallanes Computerised Impulsivity Scale (Servera & Llabrés, 2000); ESI= Emotional Symptoms Index of the BASC-2 (Behaviour Assessment for Children, Reynolds and Kamphaus, 2004); MIST-C= Milwaukee Inventory for Styles of Trichotillomania-Child Version (Flessner et al., 2007); SCS= Self Control Schedule (Rosenbaum, 1980); TSC= Trichotillomania Scale for Children (Tolin et al., 2008); YGTSS= Yale Global Tic Severity Scale (Leckman et al., 1989); AAQ-II= Acceptance and Action Questionnaire-II (Bond et al., 2011); AFQ-Y= Avoidance and Fusion Questionnaire for Youth (Greco et al., 2008); AFQ-S= Avoidance and Fusion Questionnaire Spanish version (Luciano et al., 2011); BE-Values= Bulls-Eye Values Assessment (Wilson and Murrell, 2002); CAMM= Child and Adolescent Mindfulness Measure (Ciarrochi, Kashdan, Leeson, Heaven & Jordan, 2011); KIMS= Accepting without Judgment Scale of Kentucky Inventory of Mindfulness Skills (Baer, Gregory, & Allen, 2004); MAAS=Mindful Attention Awareness Scale (Brown & Ryan, 2003); VLQ=Valued Living Questionnaire (Wilson et al., 2010)

43

Acceptability of the Intervention for Adolescents

Seven of the 20 studies assessed treatment acceptability via open ended questionnaires or

specific rating scales. Participants across all studies reported largely favourable acceptability

of the ACT interventions. Armstrong et al., (2013) and Woidneck et al., (2014) both used the

Treatment Evaluation Inventory-Short Form (TEI-SF; Kelley, Heffer, Gresham & Elliot, 1989)

and all participants gave scores over 21 indicative of treatment acceptability. Participants in

Luciano et al.’s (2011) study reported greater usefulness for the more intensive defusion

protocol. They report that all but one participant rated the intervention between 5 to 8

points (M= 5.83, SD= 2.56), indicating that one student did not find the intervention as

acceptable. Livheim et al., (2015) both Australian and Swedish studies reported positive

feedback, with 91% of students in the Swedish study providing only positive feedback and all

would recommend to a friend. In the Australian study, themes about what participants liked

about the group included, ‘we learned about feelings’, ‘we learned everyone was the same’,

and ‘it was fun’. Most people responded no to what they didn’t enjoy about the group, with

the remaining response themes being ‘it was too short’ or ‘it was sometimes confusing’.

Murrell et al., (2015) used an open-ended survey; in response to providing the intervention a

rating out of 10, participants gave a mean response of 8.71 (SD 1.97) and a modal response

of 8. The least favourable acceptability findings for an ACT intervention were in Burckhardt

et al.’s (2017) school intervention, where out of 25 participants, 75% agreed to feeling ‘more

confident’ after the intervention, 63% found the ‘workshops helpful’, 50% agreed that they

are ‘less impacted by anxiety’ and are ‘applying the workshops to everyday life’.

In addition to this Timko et al., (2015) used treatment credibility ratings in their study of

44

family based ACT for Anorexia, and found that families who rated the treatment as less

credible, were more likely for the adolescent to be referred to a higher level of care, thus

dropping out of therapy. Although reported acceptability of ACT interventions is promising,

another measure of treatment acceptability is rate of attrition, table 8 details attrition across

studies.

Table 8Attrition rates across studies

N at start Attrition Rate Post n (%) Attrition Rate Follow Up n (%)Study Total ACT Ctrl Total ACT Ctrl Total ACT Ctrl

Armstrong et al., 2013 3 0 (0)

Azadeh et al., 2016 30 15 15 0 (0)

Fine et al., 2012 2 0 (0)

Franklin et al., 2011 13 6 7 0 (0) 0 (0) 0 (0)

Gomez et al., 2014 5 0 (0)

Heffner et al., 2002 1 0 (0)

Luciano et al., 2011 15 4/5/6 0 (0)

Schneider & Arch, 2017 1 0 (0)

Swain et al., 2015b ni

Theodore-Oklota et al., 2014 210 105 105 0 (0)

Burckhard et al., 2016 267 139 128 46 (17) ni ni

Burckhard et al., 2017 48 17 31 14 (29) 2 (12) 12 (39) 20 (42) 5 (29) 15 (48)

Hayes et al., 2011 38 22 16 8 (21) 3 (14) 5 (31) 26 (68) 14 (64) 12 (75)

Livheim et al., (2015) - Aus 66 40 26 15 (23) 5 (13) 6 (23)

Livheim et al., (2015) - Swe 32 15 17 7 (22) 4 (27) 3 (18)

Murrell et al., 2015 9 2 (22)

Petts et al., 2017 11 2 (18)

Timko et al., 2015 47 16 (34)

Woidneck et al., 2014 10 3 (30)

Van der Gucht et al., 2017 586 288 298 42 (7) 15 (5) 27 (9) 307 (52) 195 (67) 112 (41)

Half of the studies showed no attrition. Where there were two groups attrition rates were

mostly similar and at times slightly lower in the ACT group, other than the Swedish study of

Livheim et al., (2015). Attrition rates post intervention were relatively high ranging from 5-

34% across ACT interventions with or without a control group. Similar attrition ranges of 9-

45

39% were found in control groups. The starkest finding was high attrition at follow-up in

three studies that reported attrition ranging from 29-67% in the ACT group and 41-75% in

controls.

D I SCUSS ION

The aim of the current systematic review was to examine the methodological quality,

effectiveness and acceptability, of all peer-reviewed literature on ACT interventions with

adolescents addressing emerging or pre-existing mental health difficulties.

Overall 20 studies applied ACT protocols across a range of preventative, mild and clinical

mental health difficulties. Interventions were delivered in both clinic and school settings

across many different countries, however this did not include the UK. Although the wide

range of difficulties, severity and settings made comparisons across studies logistically more

complex, it does highlight a positive effort across the adolescent ACT literature to address a

range of emerging and severe difficulties presenting in different settings. There also

appeared to be a recent push towards using ACT to address universal school delivered

interventions, which is in-keeping with recent NICE guidelines on universal social and

emotional learning in schools (NICE, 2009), indicative of a responsive approach adopted by

the ACT community.

Remarkably, recent publication dates were found across studies with all but one published

after 2011 and the majority (70%) published in the last three years; demonstrating the

relative infancy of the literature. In keeping with the evolving nature of this academic field,

46

75% of the studies identified as pilot, feasibility or preliminary research. Study designs varied

greatly, with only a quarter using a more robust RCT design and half the studies had small

samples. As might be expected in such a young and developing area of research, many

methodological limitations were identified.

Methodological quality ratings across studies were reduced because of small samples sizes

and almost half of the studies did not have a comparison group. Of those with a comparison

group only two studies compared ACT to existing therapeutic interventions, namely CBT

(Hayes et al., 2011; Swain et al., 2015b). Unfortunately adolescent data was unavailable for

one of these studies as this subsample was a mediation analysis of ACT process measures

(Swain et al., 2015b). However, the review found large effect sizes in favour of ACT in the

Hayes et al.’s (2011) study using ACT for depression. Disappointingly, power calculations to

determine sample size were lacking across the literature with only one RCT using a power

calculation (Swain et al., 2015b), despite the review containing four other RCT designs. This

implies that all studies may have been underpowered and thus findings should be cautiously

interpreted.

However, even across areas of methodological quality that did not require a comparison

group, there were some noteworthy methodological issues. A key problem was a general

lack of reporting, so many POSMRF items received scores of zero due to a lack of

information. Although reporting was better across the clinical compared to school studies,

checks for reliability of the diagnosis and training of assessors were unreported or absent

across studies. Importantly checks for therapist adherence and therapist competence were

47

lacking across many studies; without such checks fidelity to the protocol and quality of the

therapy cannot be ascertained. This issue was particularly relevant in two studies which

failed to make such checks but suggested that limited effects for the ACT intervention may

be linked to therapist competence. Firstly a school RCT which used teachers to deliver the

ACT intervention (Van der Gucht et al., 2017) and a habit reversal training (HRT) with and

without ACT protocols to address trichotillomania (Franklin et al., 2011). If such checks had

been completed more robust conclusions could have been drawn as to whether the lack of

effect was due to differences in competence, fidelity to the protocol, or other factors.

Methodological strengths across studies included most studies basing interventions on

publically available treatment manuals, allowing for replication in larger samples and

different environments. The use of outcome measures, which had been validated with youth

samples or designed specifically for adolescents, was another strength. However, studies

from non-English speaking countries had limited access to measures validated for youth in

the local language, so relied on translating pre-existing measures. This raises issues around

accuracy of the translation, validity and reliability of the measure and cross-cultural

applicability in the new country (Sartorius & Kuyken, 1994). However with limited options

available, formal protocols for the translation of outcome measures to ensure cultural

acceptability would be recommended for future research (e.g. Knudsen et al., 2000).

Despite issues of methodological quality, there were some very promising results across

most studies. However, due to a lack of power only cautionary interpretations of the findings

can be made. Moderate to very large effect sizes on primary outcome measures suggest that

48

ACT interventions are having a positive impact upon many mental health symptoms.

Similarly positive findings were found in studies with small samples, apart from one, which

encountered feasibility issues (Murrell et al., 2015). The universal school preventative

studies had the poorest effects (Burchardt et al., 2016; Burchardt et al., 2017; Theodore-

Oklota et al., 2014; Van der Gucht et al., 2017), which could be indicative of floor effects on

outcome measures, as the universal nature of the interventions delivered a non-clinical

sample. Or it may be related to interventions not being tailored to the needs of the students.

The use of teachers to deliver the intervention in Van der Gucht et al.’s, (2017) study was

also not effective, the authors suggest professionally trained therapists should be used in

future research.

Findings on ACT process outcomes, measuring values, experiential avoidance, psychological

flexibility, were mixed. Some studies indicated positive change and others showing little

change on these measures. This could be indicative of some interventions not targeting ACT

processes, however they still had mostly positive effects on outcome measures. Further

investigation into ACT processes is warranted, as it is important to determine whether

specific ACT processes are correlating with change. Swain et al., (2015b) conducted a

mediation analysis of ACT process measures using data from the adolescent subsample of

Hancock et al.’s (2016) ACT for anxiety study. They found that the ACT hexaflex mediated the

relationship between anxiety severity ratings in the ACT and not the CBT group. However,

this finding was strengthened by one measure - the Acceptance and Fusion Questionnaire

for Youth (AFQ-Y; Greco et al., 2008), which measures acceptance and defusion, rather than

other ACT process measures (Swain et al., 2015b). Interestingly the AFQ-Y also showed many

49

positive changes across studies in this literature review, suggesting that this could be

sensitive to ACT processes, or alternatively acceptance and defusion are areas of the

hexaflex accessible to change in adolescents. This appears to be a useful measure for future

adolescent research, however it would also be important to continue investigating the other

areas of the hexaflex, even if future research highlights a less active contribution to change

in the other hexaflex regions.

Acceptability data was largely positive in the studies that collected this; the poorest

acceptability was in a school intervention by Burckhardt et al., (2017). There was relatively

high attrition across some studies, which could be indicative of a lack of acceptability for the

intervention. However in studies with comparison groups, attrition was largely equal across

groups, if not less in the ACT group, suggesting it may not be linked to intervention

acceptability. Rather high attrition could be indicative of methodological issues, which could

explain very high follow-up attrition, which may not be indicative of dissatisfaction with the

intervention. High attrition may also be due to studies being poorly funded, the pilot and

feasibility nature is suggestive of smaller budgets; however this is not confirmed by the

articles.

There is some debate as to the usefulness of attrition rate as a measure of methodological

rigour or intervention acceptability, particularly because there is naturally high attrition

across studies with ‘harder to reach’ demographics (Amico, 2009). Instead, some have

suggested reporting baseline characteristics of all participants, in addition to separately

reporting characteristics of participants that were lost at follow up and provide direct

50

comparisons between completers and drop-out compared to those in analysis (Dumville,

Torgerson & Hewitt, 2006).

Conclusions

Despite methodological weaknesses across studies, many successful attempts have been

made to apply ACT and acceptance based therapies to working with adolescents. Studies in

clinical settings found moderate to large effects, however universal school-based

interventions have shown less promise. More rigorous methodological processes in future

research, particularly in school studies will aid understanding of effects; for example how

much therapist competence or adherence to the protocol may be impacting. Similar to the

beginning stages of CBT, methodological quality will suffer due to lack of funding and

available resources (Gaudiano, 2009). However in spite of these issues, there are promising

outcomes and a sense of growing momentum in the adolescent ACT literature.

Directions for Future Research

Ideally future studies will include UK applications of ACT to adolescents and more large-scale

RCT’s. The rapid increase in publications applying ACT to adolescents in recent years is a

positive sign for future RCTs. As this is an emerging evidence base, future research will

inevitably require further pilot or stage 1 studies, however the methodological quality of

these can be improved. Future studies should ensure checks of therapist competence and

fidelity to the protocol, independent evaluators, including comparison groups where

possible, precise reporting of protocols in method sections, and appropriate translation

51

procedures of outcome measures.

Future research should use precise reporting of demographic factors such as, gender,

ethnicity and socio-economic status. Analysis of the role of these demographic factors on

the intervention effectiveness should be incorporated. Equally in future research, comorbid

difficulties should be controlled for; particularly as ACT is a transdiagnostic approach, it

would be interesting to see the effectiveness of ACT with both comorbid and singular clinical

difficulties. The expansion of ACT interventions in schools is a further new area of research,

this could be expanded upon by studies incorporating outcomes which capture the

perspective of the school, for example detentions, rewards, punctuality. As with all clinical

intervention studies, mediation and moderation analysis is an important step towards

understanding the processes and factors underlying change. The use of mediation analysis in

Swain et al.’s, (2015b) study is a positive sign for such an emerging area of research.

Mediation and moderation analysis is recommended to understand impact of the different

ACT hexaflex areas, or other processes augmenting change in therapy.

Limitations of the current review

In the current systematic review, only peer review articles were included for quality

purposes, however in doing so the review failed to account for unpublished ‘grey’ literature;

as this is an emerging and expanding area, future reviews of the grey literature may be

helpful. Additionally, Öst (2014) raised concerns around publication bias leading to

subsequent inflated effect sizes, examinations of ‘grey literature’ may help appease these

concerns. The standardised calculation of effect sizes across primary outcomes allowed for

52

helpful comparison of effects across studies. Although the pooling of effect sizes from

diverse, non-randomised studies has not been recommended (Sterne, Egger & Moher,

2008), the current review is not a meta-analysis, as such comparisons were used as a guide,

indicating positive or negative results, rather than conclusive evidence. Finally, the POSMRF

rating scale (Öst, 2008) was selected to assess methodological rigour across studies, as this

had been used in previous review of ACT literature (e.g. Öst, 2008; 2014; Smout et al., 2012;

Swain et al., 2013; Swain et al., 2015a). However, this measure focuses on clinical

diagnosable difficulties, which was not so applicable to studies with a preventative focus,

and is not in keeping with the transdiagnostic approach used in ACT. Future studies may

wish to choose an alternative methodological rating scale (for review refer to, Katrak,

Bialocerkowski, Massy-Westropp, Kumar & Grimmer, 2004).

53

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PART TWO - MRP EMPIRICAL PAPER

T ITLE: ‘Taking ACTion On Anger’: A School Perspective of the Feasibility and Preliminary

Efficacy of a Brief ACT Intervention for Anger in Adolescent Males

WORD COUNT: 8384

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ABSTRACT

Adolescent boys are diagnosed with mental health difficulties more frequently than girls;

often this diagnosis is linked to maladaptive expressions of anger. In schools adolescent boys

are underachieving compared to females and are three times more likely to be excluded.

Interventions targeting maladaptive expressions of anger, tailored specifically to adolescent

boys are warranted. The current feasibility study examined the efficacy of a novel school-

based acceptance and commitment therapy (ACT) intervention, targeting anger difficulties in

adolescent males. The study adopted a mixed methods design using teacher completed

outcome measures and qualitative interview data to explore the impact of the intervention

from the school perspective. Separate interviews were conducted with school staff to assess

feasibility. Quantitative results found significant decreases in school penalties and teacher

observed emotional difficulties, however only cautionary interpretations can be made due to

the study being underpowered. Qualitative findings noted the boys reflecting and taking

ownership over their behaviour, and highlight the importance perceptions of the group and

the teacher-student relationship, whilst positioning the findings within the wider system

with expectations of change occurring over a longer duration. Fidelity to the protocol was

compromised due to feasibility issues, and feasibility interview data emphasises the

importance of embedding the intervention within the pre-existing school system. In

conclusion the development of the Taking ACTion on Anger intervention, based on the ACT

Hexaflex showed preliminary efficacy with adolescent boys. Suggestions for future

developments are provided.

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INTRODUCTION

The emotional wellbeing of adolescent boys is of growing concern. Compared to adolescent

girls, more boys are referred to child and adolescent mental health services (CAMHS) and

receive a mental health diagnosis (Green, McGinnity, Meltzer, Ford & Goodman, 2005;

Meltzer, Gatward, Goodman & Ford, 2000). Anger is a common emotional response to

problem situations during adolescence; reportedly experienced at a greater frequency,

intensity and duration compared to adults or older adults (Birditt & Fingerman, 2003;

Blanchard-Fields & Coats, 2008). Problem behaviours linked to a maladaptive expression of

anger, such as verbal aggression, defiance, violence, impulsive or oppositional behaviour, are

more prevalent in boys than girls (Archer, 2004; Liu, 2006; Zahn-Waxler, Shirtcliff, &

Marceau, 2008). These behaviours have been coined ‘externalising’ difficulties (Achenbach

1978; 1991) whereby emotional distress is expressed outwardly on the external

environment through behaviour. Such behaviours result in adolescent boys receiving formal

diagnoses that incorporate manifestations of anger; diagnoses include, conduct disorder

(CD), oppositional defiant disorder (ODD), or hyperactivity disorders (American Psychiatric

Association, 1994; Green et al., 2005; Meltzer et al., 2000). In fact, approximately two

adolescent boys in each UK classroom will have a CD diagnosis (Green et al., 2005). If

unaddressed, maladaptive expressions of anger in childhood are a strong predictor of adult

violence and crime (Moffitt, 1993).

In school, boys are falling behind their female counterparts. Academically only 59% of boys

in English state funded schools achieve GCSE grades A*-C compared to 67% of girls

(Department for Education, 2017). Boys are also three times more likely to be either

69

temporarily or permanently excluded from school (Department for Education, 2016).

Persistent disruptive behaviour is the most common reason for exclusion in the UK; this

includes challenging behaviour, disobedience and repeated violation of school rules

(Department for Education, 2016).

If a maladaptive response to anger is leading to disruptive behaviour in school, then the

problem behaviour will likely overshadow the underlying emotional distress, resulting in

disciplinary action and possible exclusion rather than emotional support (Ford, Parker, Salim,

Logan & Henley, in press; Parker et al., 2014; Whear et al., 2014). A number of detrimental

consequences emerge if the underlying emotional distress is not addressed. For the

adolescent, a pattern of persistent disruptive behaviour may develop as they lack the

emotional literacy, psychological flexibility and interpersonal skills to respond to future

experiences of anger (Evans, Harden, Thomas & Benefield, 2003; Green, 2014). Externalising

behaviours are associated with rejection from peers, and time spent being disciplined

reduces the likelihood of reaching their academic potential (Arnold et al., 1999; Morrison,

Furlong, D’Incau, & Morrison, 2004; Taylor & Biglan, 1998). For teachers, repeated exposure

to these behaviours has a detrimental impact upon stress levels and can lead to burnout;

which in turn causes teachers to be less tolerant of challenging behaviours (Kokkinos,

Panayiotou & Davazoglou, 2005), further perpetuating the problem. For other pupils,

externalising behaviours reduce time engaged in learning and divert limited resources to

managing behavioural problems rather than providing educational assistance (Rose &

Gallup, 2005). Moreover, prolonged exposure to disruptive classrooms can lead previously

non-aggressive students to develop aggressive behaviours (Thomas, Bierman & The Conduct

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Problems Prevention Research Group, 2006). Overall these behaviours have the potential to

cause serious harm to the adolescent, teacher and wider class, compromising opportunities

for positive educational or social engagement, emotional wellbeing and access to future

opportunities; which are precursors to good emotional and psychological well-being (Barnes,

Green & Ross, 2011; Coleman, 2007; NICE, 2009; 2013b)

Interventions aimed at reducing maladaptive anger-expression and externalising problem

behaviours in adolescent boys are a fundamental step towards, improving their

psychological wellbeing, opportunities for engagement in education and contribute benefits

for the wider class. Existing treatments such as Multi-Modal Systemic Therapy (MST) have a

robust evidence base (Littell, Campbell, Green and Toews, 2005) and are recommended for

adolescents with conduct disorder (NICE, 2013a). Although effective, MST is costly and

resource-intensive, so are only available to young people with severe aggression and

antisocial behaviour difficulties. However poorer academic achievement and increases in

school exclusions amongst adolescent boys, is indicative of a current need for interventions

designed specifically for adolescent males with emerging and less severe anger difficulties in

educational settings.

A less resource intensive and widely researched treatment approach for anger and

aggression problems is Cognitive Behavioural Therapy (CBT). However CBT studies use a

broad spectrum of approaches including psycho-education about emotional states,

behaviour modification and cognitive skills training, or a combination of these (Blake &

Hamrin, 2007). A recent meta-analysis comprising 25 CBT interventions aiming to reduce

71

aggression in young people showed a moderate weighted mean effect size (d= 0.50)

(Smeets, Leeijen, van der Molen, Scheepers, Buitelaar & Rommelse, 2015). However there

was a large variation, with effect sizes ranging from d= -0.19 to d= 2.35. Contextualising

these findings the meta-analysis included young people in primary education up to 23 years

old (mean age 10.78 years). These outcomes are in keeping with previous effect sizes for CBT

interventions addressing anger and/or aggression in young people, (Sukhodolsky, Kassinove,

& Gorman, 2004; Fossum, Handegård, Martinussen, & Mørch, 2008). To address the

variation in approach across CBT interventions for anger, Sukhodolsky et al.’s, (2004) meta-

analysis grouped the interventions by type; namely skills development, affective education,

problem solving, and mixed approaches. They found interventions that taught behaviours,

namely skills development or mixed approaches, rather than attempted to modify internal

constructs linked to anger behavior, showed greater effects (skills development, d=0.79;

mixed approaches, d=0.74, affective education d=0.36).

Although effective for some, CBT approaches to anger do not meet the needs of all young

people. Anger has been repeatedly linked to emotional pain (Berkowitz, 1993), and often

masks additional unwanted feelings such as shame, embarrassment, and disempowerment

(Eifert, McKay & Forsyth, 2006; McKay, Rogers & McKay, 2003). CBT approaches aim to

“challenge” the content of anger cognitions, and “manage” anger feelings and subsequent

behaviours; however few interventions address the processes that cause this hidden

emotional pain to develop into anger (Eifert & Forsyth, 2011). Acceptance and Commitment

Therapy (ACT) is a ‘3rd-wave' behavioural therapy that takes a transdiagnostic approach to

mental health difficulties (Harris, 2009) which approaches anger differently. ACT proposes

72

that strong emotions are near impossible to control, or change; rather than challenging the

content of anger cognitions it focuses on ones relationship with the cognition or emotion

(Harris, 2009; Hayes, 2004). ACT aims to increase “psychological flexibility”, where rather

than trying to tolerate or avoid experiencing difficult emotions such as anger, instead it

encourages “acceptance” through mindfully and non-judgementally experiencing difficult

internal experiences, whilst behaving with “commitment” to personal values (Harris, 2008).

The emerging evidence base for ACT has demonstrated effectiveness with a range of

psychological difficulties in adults (Hayes, 2008; Hayes, Luoma, Bond, Masuda & Lillis, 2006;

Ost, 2014) and is showing promise with young people (Coyne, McHugh & Martinez, 2015;

Swain, Hancock, Dixon & Bowman, 2015). Ruiz’s (2012) meta-analysis showed superior effect

sizes for ACT over CBT interventions, although this finding has not been replicated in other

meta-analyses (Ost, 2014; Powers et al., 2009). Halliburton & Cooper (2015) explored

specific developmental adaptations when using ACT with adolescents; in recognition of

increased peer-group influence in adolescence they highlight the benefits of group ACT

interventions. ACT is a behavioural therapy which endorses the use of mindfulness and

experiential exercises throughout; this focus on learning through doing and experiencing

links to Sukhodolsky et al.’s, (2004) finding that skill development was a key factor in

successful CBT interventions.

When applied to anger difficulties, the ACT research literature is underdeveloped. ACT

incorporates a mindfulness component, which has shown promise in reducing aggressive

behaviours in youths with autistic spectrum disorder (Singh et al., 2011). One study

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investigating ACT applied to anger in an adult sample, found moderately large effect sizes

(d=0.76) on problematic behaviours, however the sample sizes were small (Eifert & Forsyth,

2011). Another study delivered a universal 3-session ACT intervention addressing relational

aggression to an entire school year group (Theodore-Oklota, Orsillo, Lee & Vernig, 2014). The

non-selective sample included both victims and perpetrators of relational aggression and

unfortunately the intervention did not reduce frequency of relational aggression but did

increase problem solving coping in the adolescents receiving the intervention. Although the

evidence base is in it’s infancy, ACT offers an alternative therapeutic model for a novel

intervention. The individualised values based approach, use of metaphors and interactive

experiential format allows for the development of adaptations suited to adolescent males.

Schools provide consistent and regular input into the lives of adolescents; social

development and interpersonal conflicts occur within school, making them an apt

environment for delivery of adolescent interventions (The Multisite Violence Prevention

Project, 2009). Moreover, well executed school based interventions can be successful in

generating improvements across academic, behavioural, personal attitude and emotional

domains for a variety of problems including anger (Mytton, DiGuiseppi, Gough, Taylor &

Logan, 2006; Durlak, Weissberg, Dymnicki, Taylor & Schellinger, 2011).

The current study addressed the need for interventions designed expressly for adolescent

males, whilst contributing to the ACT intervention literature. A novel 5-week school-based

ACT group intervention, ‘Taking ACTion on Anger’, was developed specifically for adolescent

males experiencing anger and aggression difficulties. The intervention was based on current

ACT protocols for adolescents in distress (Ciarrochi, Hayes & Bailey, 2012) and adults

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experiencing difficulties with anger (Eifert, McKay & Forsyth, 2006). A mixed methods

approach was adopted to explore the school’s perspective of effectiveness1 and an

additional embedded qualitative analysis examined feasibility and acceptability. Teachers

provide a reference point of normative behaviour and a different perspective of change.

They are in contact with parents and form part of the wider system supporting the child;

thereby offering a valuable perspective on the impact and acceptability of the intervention

for both the adolescent and the wider school and social network.

Exploratory research questions:

1. Do the teachers observe changes in behaviour or school conduct in the

adolescents’ after receiving the ACT intervention?

2. What factors may be impacting upon the effectiveness of the ACT intervention?

3. How feasible is it to deliver an ACT intervention within the school system?

It was hypothesised that the intervention would deliver reductions in school awarded

penalty points and problem behaviour subscales on the Strengths and Difficulties

Questionnaire – Teacher rated (T-SDQ; Goodman, 1997), whilst delivering improvements in

pro-social behaviour subscale on T-SDQ, attendance/punctuality rates, and school reward

points. As the study was underpowered, only cautionary interpretations of quantitative data

could be made.

1 A second study will examine the effectiveness from the adolescent male’s perspectives.

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METHOD

Design

A mixed methods design explored the teachers’ perspective of the effectiveness, feasibility

and acceptability of delivering the ‘Taking ACTion on Anger’ intervention in a school

environment.

Firstly, a convergent parallel mixed methods design was used to explore the effectiveness of

the intervention on the adolescents’ behaviour, participation and conduct in school, from

the teachers’ perspective. This mixed methods approach, allowed for separate analysis of

quantitative and qualitative data, which was later compared and integrated to attain a fuller

picture of the impact and effectiveness. Quantitative teacher-rated questionnaires and

routinely collected school-based measures, offered a standardised comparison of change

across all participants. A quasi-experimental pre-post intervention design examined change

in quantitative measures at pre, post and 3-month follow-up time-points. However

participant numbers were small resulting in low power, thus limiting interpretation.

Qualitative teacher interview data offered a more detailed picture of change processes and

an understanding of the possible mechanisms underlying change. A thematic analysis of

teacher interviews explored their perception of change in the adolescents’ school conduct.

Regarding feasibility, interview data from school leaders, intervention co-facilitators and

teachers was subjected to an embedded thematic analysis.

Participants

The study had three participant groups, which met the inclusion and exclusion criteria

detailed in table 1:

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1. Adolescent group participants were fifteen adolescent male students in years 8 or 9,

who received the ‘Taking ACTion on Anger’ intervention

2. Informant teacher participants were two female teachers who took a lead in

behaviour management for years 7-9 in the school. They completed quantitative

outcome measures and participated in semi-structured interviews regarding the

adolescent participants.

3. Feasibility participants were 7 members of school staff who completed semi-

structured feasibility interviews. The school principal, two school leads, two

intervention co-facilitators, and the two informant teachers also contributed to this

dataset.

Table 1Participant inclusion and Exclusion Criteria

Participant Group Inclusion Criteria Exclusion Criteria

Adolescent Group Participants

Males Age 13-14 / year 8 or 9 Attending the identified school Identified by school as displaying a

moderate level of difficulty managing anger/aggression

Determined by school staff to: Be at high risk to self or others Have current severe and/or enduring

mental health difficulty Not in mainstream schooling Neurodevelopmental disorder Unable to speak or read English

Informant Teachers Teacher at identified school Had regular (minimum twice weekly)

contact with the adolescent Was able to comment on behavioural

change.

Feasibility Participants

A member of staff with a connection to the intervention

Data Collection Tools

Effectiveness of the programme was assessed using a validated teacher-report

questionnaire; the Teacher-Strength and Difficulties Questionnaire (T-SDQ; Goodman, 1997;

77

appendix 5) and four routinely collected school based outcome measures; penalty points,

reward points, attendance and punctuality.

T-SDQ is a 25-item self-report informant questionnaire (Goodman, 1997). Teachers

comment on statements relating to the child’s behavioural strengths and difficulties, e.g.

‘Often has temper tantrums or hot tempers’. Responses are scored 0-2 using a 3-point likert

scale; ‘not true’, ‘somewhat true’, or ‘certainly true’. The measure has 5 subscales: (1)

emotional problems, (2) conduct problems, (3) hyperactivity/ inattention problems, (4) peer

relationship problems, (5) pro-social behaviour. A total difficulties score consists of the total

of the scores for subscales 1-4. In a community sample of 5-15 year olds the scale showed

robust validity and reliability (Goodman, 2001). Table 2 shows clinical norms for each

subscale, amount of change needed to elicit reliable change and further details. Baseline

cronbach alphas for the sample are also detailed, however these are somewhat below

acceptable limits. The small sample size and the small number of items (n=5) within each

subscale could be contributing to low alphas (Cortina, 1993). As such all T-SDQ (Goodman,

1997) subscales other than emotional symptoms and peer relationships should be examined

cautiously.

Table 2

Subscales of the Teacher rated Strengths and Difficulties Questionnaire (T-SDQ)

Number of Items Range

aGoodman Reliability

(a)

bSample Baseline

Reliability (a) RCI

Clinical

cut off normalborder

-line abnormalT-SDQ: Total Difficulties

20 0-40 0.87 0.63 4.86 <12 0-11 12-15 16-40

T-SDQ: Emotional Symptoms

5 0-10 0.78 0.83 3.27 <5 0-4 5 6-10

T-SDQ: Hyperactivity / Inattention

5 0-10 0.88 0.73 1.97 <6 0-5 6 7-10

T-SDQ: Conduct Problems

5 0-10 0.74 0.66 1.73 <3 0-2 3 4-10

T-SDQ: Peer 5 0-10 0.84 0.49 2.36 <4 0-3 4 5-10

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Relationship ProblemsT-SDQ: Prosocial Behaviour

5 0-10 0.70 0.89 3.72 <5 6-10 5 0-4

Notes. a Goodman, 2001; b cronbachs for current sample; a= cronbach's alpha; RCI = Reliabile change index, details the minimum amount of change on the subscale, for it to be reliable and not due to chance. RCI was determined using the Morley & Dowzer, (2014) RCI calculator. T-SDQ= Teacher rated Strengths and Difficulties Questionnaire (Goodman, 1997)

School based measures are described in table 3. These measures were collected routinely

within the school using an electronic recording system.

Table 3

School Based Outcome Measures

Measure Timepoints Description

School Penalty Points

Pre, post, 3mth f-up

School staff give between 1 and 4 penalty points for problematic behaviours at school. A greater points value relates to severity of behaviour and consequence of that behaviour.

1 = initial warning (e.g. talking in class); 2 = 30 minute detention (e.g. persistent 1 point behaviours); 3 = 1 hour detention (e.g. repeatedly late to lessons); 4 = 2 hour detention (e.g. verbal aggression to staff or student)

School Reward Points

Pre, post, 3mth f-up

School staff give reward points for positive behaviours at school; reasons include good behaviour; positive class work, continued achievement or improvement, ranging to specific school awards for sports etc. Reward points are given in multiples of 10, a greater number of points are awarded for larger achievements.

Attendance Pre, post, 3mth f-up

Total Absences – combined number of days when the child is not at school. A combined score for all absences detailed below.

Pre, post, 3mth f-up

Explained Absence – number of days where the child is absent and a reason is provided, for example a parent informs the school that the child is unwell.

Pre, post, 3mth f-up

Unauthorised Absence – number of days where the child is absent but no reason is provided, or this is not authorised by an adult.

Pre, post, 3mth f-up

Exclusions – Number of days where the child is excluded from their usual classes at school. This includes internal exclusion, educated off site, for example in a Pupil Referral Unit (PRU), and external exclusion.

Punctuality Pre, post, 3mth f-up

Number of times late for registration (occurring twice daily)

NB. All school based measures were a total over a period of 20 school days. Pre covers the 20 school days before informed consent and pre-questionnaires were collected; post covers the 20 school days after the final intervention session. Follow up covers a period of 20 days before 3 months after the final intervention session.

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Qualitative Measures

Four interview schedules were developed for the study; two focussing on feasibility and two

on the impact of the intervention (appendices 6a-e). Schedules were designed through

discussions with the school Principal and project team, consisting of another Trainee and the

Supervisor who is a qualified clinical psychologist and research supervisor. Two ‘feasibility’

interview schedules assessed the feasibility of integrating the intervention into the school

system. Questions related to human resource, financial, time, psychosocial costs and

benefits of additional demands created by the study. The feasibility participant group were

interviewed at two time points: at the outset of the project to gather a perspective of the

school’s expectations of delivery and disruption caused by running the intervention, and at

the very end of the project.

The ‘post’ and ‘follow-up’ schedules were carried out with informant teacher participants

immediately after (post) and 3-months after (follow-up) the intervention had occurred. They

explored the informant teachers’ perspective of the impact of the intervention on the boy’s

behaviour and conduct at school. The follow-up interview inquired whether gains realised by

the pupils were maintained or any further changes in school conduct had occurred. These

interviews also included feasibility questions asked at the first and final interviews with each

informant teacher participant.

Ethical Approval

The project received favourable ethical approval from the University of Surrey Faculty of

Health and Medical Sciences Ethics Committee (appendix 2). All participant groups were

provided with information sheets explaining the study and before signing consent forms

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(appendix 3a-d). They were offered the right to withdraw their data until the point of

anonymisation. Due to the age of adolescent participants, parents and carers were written

to with information about the study (appendix 4) and verbal parental consent was also

obtained by telephone. The schools safeguarding procedures were followed and any

concerns were fed back to the group co-facilitator and followed up in writing.

Development of the ‘Taking ACTion on Anger’ Group Intervention

The study team developed the ‘Taking ACTion on Anger’ intervention using two current ACT

protocols, a transdiagnostic self-help book for adolescents in distress (Ciarrochi, Hayes &

Bailey, 2012) and an anger specific protocol for adults (Eifert, McKay & Forsyth, 2006). The

protocol was developed to incorporate six areas of the ACT hexaflex (Harris, 2009), and a

Clinical Psychologist who specialises in ACT examined adherence to the model. Consultation

was held with three adolescent males to examine the gender and developmental

appropriateness of the metaphors and activities.

The program followed a specifically developed workbook that the boys could use to

complete activities and as a reminder of the session. Each session began with a mindfulness

exercise followed by activities to introduce and explore the ACT concepts. Three main

characters; ‘Anger Tiger’, ‘Mindless Zombie’, ‘Wise Warrior’; and a ‘choice-point’ were used

as metaphors to portray ideas and were reintroduced throughout the intervention. Sports

personalities and celebrities were used to exemplify activities. Where possible the interests

of the boys within each group were determined and taken account of in early sessions, to

tailor activities and discussions to these interests. Appendix 7 contains the session protocol,

including ACT hexaflex domain covered, activities and session structure.

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Figure 1. Study Procedure

After 3 cycles of the ACT

group

Final feasibility interviews were conducted with feasibility participants.

3 months after the

intervention

Repeated over a half school

term for 3 cycles of the ACT group

Brief follow-up interviews were carried out with informant teachers. School-based outcome

measures were downloaded from the school’s electronic record system.

Post T-SDQ’s were collected and 20-30 minute interviews were undertaken with informant teachers.

Concurrently pre T-SDQ’s for each boy was collected from informant teachers.

Taking ACTion on Anger group was delivered over 4-5 weeks

One week before the intervention a pre session was held with group participants.

The study team and co-facilitators approached prospective adolescent participants to obtain informed consent.

Parents were telephoned to obtain verbal consent

Parents were sent a letter informing them of the intervention.

Lead school staff identified potential participants.

Before the intervention

Feasibility and expectation interviews were conducted with feasibility participants.

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Procedure

The ‘Taking ACTion on Anger’ intervention was delivered to three groups of between 4-7

adolescents by two trainee clinical psychologists and a co-facilitator from the school. Five

weekly one-hour sessions during a non-core subject lesson,

and two weekly between-session homework and mindfulness practices carried out by the

school co-facilitator were planned. This timeframe fitted within half a school term. Figure 1

shows a diagram of the full procedure.

Data Analysis

Data analysis occurred in three stages; the first two stages examined the effectiveness and

impact of the intervention on the adolescents from the schools’ perspective. The

quantitative data was initially analysed followed by qualitative data. The third stage was an

embedded thematic analysis, examining the feasibility of delivering the intervention within

the school context.

Stage 1: Effectiveness – Quantitative

Histograms were used to explore the distribution of the data (appendix 8), however with

only 14-15 data points deviations from Normality were difficult to assess. Therefore

parametric tests were used as these are more powerful and flexible (Field, 2013), but non-

parametric alternatives were also conducted to check robustness of the parametric results.

For each quantitative outcome measure, (school penalty and reward points; attendance;

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punctuality; T-SDQ subscales and total scores; Goodman, 1997), repeated measures analysis

of variance (RM-ANOVA) models were fitted to examine the differences between the means

at the three time-points (pre, post and 3-month follow-up) and to test for linear trends over

time. Differences across the three time-points were also examined using the equivalent

nonparametric test, Friedman’s test, for comparison with the RM-ANOVA results. Where

significant differences between time-points were found and robustness of this finding was

verified by non-parametric Friedman’s test, post hoc tests examined level of change

between each pair of time-points. Graphs of means at each time-point were generated for

outcome measures to provide a visual representation of patterns over time.

Effect sizes (ES) for each outcome were calculated to examine the magnitude and direction

of change from pre to post, and pre to follow-up time points. Repeated measures Cohen’s d

was calculated using the method suggested by Gibbons and colleagues, (Gibbons, Hedeker,

& Davis, 1993) where the mean difference between time-points, (change scores), is divided

by the standard deviation of the change scores.

< NB. Figure 2 has been removed to avoid breaches of copyright >

Figure 2. RM-Effect Size Calculation.

There is some debate about whether to use the standard deviation of the change scores or

the standard deviation of the pre-intervention measures for repeated measures effect sizes

(Kline, 2004) but the decision taken was to use the SD of the differences here.

Finally, case-by-case level analysis of the T-SDQ subscales (Goodman, 1997) were conducted,

84

to estimate proportions of participants exhibiting reliable change (RC; Jacobson & Truax,

1991) and clinically significant change (CSC). RC determines the minimum amount of change

required in a measure for the change not to be due to chance, and CSC is when scores on a

measure move into the non-clinical range. This analysis was not possible for the school-

based outcome measures as there was no available data on reliability or clinical cut-off

points for these measures. RC scores were calculated for each participant for each subscale,

using Morley & Dowzer’s (2014) RC Index calculator; a table of RCI and CSC for each

participant can be found in appendix 9. Cronbach alpha’s for each subscale (Goodman, 2001)

were inputted into the calculator along with raw data. Where RC was detected, results were

examined for CSC using the original 3-band categorisation, ‘normal’, ‘borderline’ and

‘abnormal’ for the T-SDQ (see 2 http://sdqinfo.org/py/sdqinfo/c0.py 3 ; Goodman, 1997), see

table 2 for CSC and RC scores for each T-SDQ subscale.

Stage 2: Effectiveness – Qualitative An inductive thematic analysis of the teacher interview

data assessed the teacher’s appraisal of impact upon the adolescents. Themes of change or

factors impacting upon change from the teachers perspective were identified.

Stage 3: Feasibility – Qualitative To establish the feasibility of delivery in a school context,

an inductive thematic analysis was carried out on data from interviews with the wider school

system. This was pooled with feasibility responses from the informant teacher interviews.

The thematic analysis in stages 2 and 3 followed Braun and Clarke’s (2006) six phases.

2 These categories are developed from a UK sample, however a peer-reviewed publication does not exist for these norms. 3

85

Familiarisation with the data, (phase 1) was achieved through transcribing the interviews,

transcripts were then re-read noting items of interest. Extracts that appeared interesting

were collated into initial groups of codes (phase 2). Similarities and links between codes

were used to generate themes (phase 3). The robustness of each theme was examined

against collated extracts and entire transcripts (phase 4). Themes were named and clear

definitions of each theme were generated (phase 5) and written up using examples to

illustrate each theme (phase 6).

Throughout the qualitative analysis process, on going discussions with the research

supervisor were held, pertaining to the quality and validity of the themes generated. These

discussions included reflections on the researchers personal biases and how these may

influence the data analysis.

The discussion section presents triangulation between qualitative themes of change

processes and quantitative data. Highlighting possible explanation for the impact and

effectiveness of the ACT intervention on behaviour, school conduct and participation.

RESULTS

The results provide a description of the sample and then report on the effectiveness of the

intervention from the vantage point of the teachers using mixed methods. Quantitative

results are followed by qualitative analysis of informant teacher interviews. The final section

assesses the feasibility of delivering the ACT intervention in a school setting using a thematic

analysis of feasibility interview data.

86

Description of The Sample

The data was collected for the 15 boys who completed the group intervention (see table 4).

Initially 18 participants were approached to participate in the group. One chose not to

participate. A second attended 3 sessions and then moved schools, and a third dropped out

of the group after attending 2 sessions. Information is not available for these 3 boys, only the

15 completers will be reported on.

Table 4

Sample Characteristics

Characteristic ACT Group

N= 15

N in group 1 7

N in group 2 4

N in group 3 4

Age, M (SD) 13.7 (0.45)

Age range 12 - 14

Ethnicity, n (%)

Black or Black British 11 (73%)

Mixed / Dual Background 2 (13%)

White 2 (13%)

Receiving aSEN support, n (%) 3 (20%)

Severity of deprivation of participant’s neighbourhoodb

10% most deprived neighbourhoods 2 (13%)

10% ≤ 20% most deprived neighbourhoods 5 (33%)

20% ≤ 30% most deprived neighbourhoods 6 (40%)

30% ≤ 50% most deprived neighbourhoods 2 (13%)

notes: aSpecial Educational Needs, bEnglish Indices of Deprivation

One participant was later temporarily educated at a pupil referral unit, which coincided with

the timescale for follow-up data collection. Therefore, follow up penalty points; reward

points; and punctuality were unattainable as this participant was not at the school.

87

The adolescent participants were 12-14 years old, mean age 13.7 (SD 0.45). The majority of

the participants were from black or mixed ethnicity backgrounds (87%). According to the

English indices of deprivation 2015, a statistic of socioeconomic deprivation based on

postcodes and generated by the UK government (Department for Communities and Local

Government, 2015), the majority (87%) of the boys lived amongst the 30% most deprived

neighbourhoods in the country. With two (13%) amongst the 10% most deprived

neighbourhoods.

Part 1 – Quantitative: Analysis Of Effectiveness

Table 5 provides a summary of the main results. The means for each variable at each time-

point are given in tables 5 and 6 and shown graphically in figures 3-10, allowing for visual

interpretation of change. Table 5 also shows statistics for RM-ANOVA’s and linear trends for

each outcome along with Friedman’s test to assess robustness of the parametric finding.

Repeated measures effect sizes (Gibbons, Hedeker, & Davis, 1993) for each variable between

pre–post, and pre–follow-up time-points are presented, along with an interpretation of the

magnitude and direction of change. Direction of change is denoted by arrow direction

(increase/decrease) and magnitude of change is denoted by number of arrows; magnitude is

based upon Cohen's descriptions: 0.20-0.49 = small, 0.50-0.79 = moderate, ≥0.80 = large.

88

Table 5

Main Quantitative Results

Descriptive Statistics Inferential Statistics Effect Sizes

Measure Pre Post 3 month F-up RM-ANOVA Linear Trend Friedman Pre – Post Pre – F-upMean (SD) Mean (SD) Mean (SD) F p F p x 2 p d int. d int.

School Penalty Points a 17.86 (11.83) 13.1

4

(9.41) 9.43 (7.01) 5.288 .02* 9.373 .01* 6.873 .03

*

-0.40 -0.82*

School Reward Points a 72.14 (48.07) 88.5

7

(67.12) 72.14 (33.55) 0.431 .66 0.000 1.00 0.038 .98 0.19 - 0.00 -

Attendance: Total Days Absent 0.27 (0.50) 1.07 (2.05) 1.77 (5.24) 1.118 .36 1.175 .30 0.867 .65 0.40 0.28

Punctuality: Lates a 1.29 (1.49) 1.79 (1.53) 1.86 (1.99) 2.992 .09 1.434 .25 4.39 .11 0.53 0.32

T-SDQ: Total Difficulties 13.80 (4.86) 12.2

0

(3.61) 12.27 (4.56) 1.086 .37 1.293 .28 3.321 .19 -0.39 -0.29

T-SDQ: Emotional Problems 2.80 (2.51) 1.87 (1.69) 1.60 (2.20) 4.367 .04* 8.308 .01* 7.625 .02

*

-0.51

-0.75*

T-SDQ: Hyperactivity / Inattention 5.73 (2.05) 5.07 (1.94) 5.20 (1.70) 1.315 .30 0.768 .40 0.894 .64 -0.44 -0.22

T-SDQ: Conduct Problems 2.93 (1.22) 2.93 (1.71) 3.27 (2.15) 0.519 .61 0.368 .55 1.244 .54 0.00 - 0.15 -

T-SDQ: Peer Relationship Problems 2.33 (2.13) 2.33 (1.18) 2.20 (1.47) 0.161 .85 0.157 .70 0.341 .84 0.00 - -0.10 -

T-SDQ: Pro-social Behaviour 5.00 (2.45) 5.60 (3.04) 4.47 (2.85) 3.988 .05* 1.431 .25 4.596 .10 0.25 -0.31

89

notes: a n=14; pre= pre intervention, post = post intervention, F U= 3 month follow-up; RM-ANOVA= Repeated Measures Analysis of Variance; d= Cohen’s d for Repeated measures; *= p<0.05; interpretation of effect size is based on Cohen's descriptions: 0.20-0.49 = small, denoted by 1 arrow; 0.50-0.79 = moderate, denoted by 2 arrows; ≥0.80 = large, denoted by 3 arrows. Upward arrow denote increase; downward arrow denotes decrease. T-SDQ= Teacher rated Strengths and Difficulties Questionnaire (Goodman, 1997)

90

School-based Measures

Pre Post 3-month F-up02468

101214161820

School Penalty Points (n=14)

Mea

n

Figure 3. Mean school penalty points

Mean school awarded penalty points showed a gradual decline across the three time-points,

shown visually in figure 3. RM-ANOVA’s showed a significant difference in school penalty

points across time-points, F (2, 12)=5.228, p=.02. This significant difference was maintained

when using Friedman’s non-parametric test, X2 (2, n=14) = 6.873, p=.03; indicating a robust

result. Bonferroni post-hoc comparisons showed mean penalty points at follow-up were

significantly lower than at pre-intervention (d= -0.82). Although the difference between pre

and post time-points did not reach significance (d= -0.40), there was a significant downward

linear trend over time, F (2, 12)=9.373, p=.01.

There was a slight increase in mean school awarded reward points from pre to post time-

points, however size of this effect was trivial and did not reach ‘small’ categorisation

(d=0.19). By follow-up reward points returned to pre-mean value, showing no effect

between pre to follow-up time-points (d=0.00) (figure 4). There was no significant difference

91

between means or trend over time.

Pre Post 3-month F-up0

1

2

3

Attendance and Punctuality

Punctuality: Half-Days Late (n=14)

Attendance: Days Absent (n=15)M

ean

Figure 5. Mean attendance and punctuality

Unexpectedly, attendance and punctuality both increased following the intervention (figure

Pre Post 3-month F-up0

1

2

3Attendance and Punctuality

Punctuality: Half-Days Late (n=14)

Attendance: Days Absent (n=15)M

ean

Figure 4. Mean school reward points

92

5). Compared to pre intervention, attendance rates increased slightly at post and follow-up

time-points, however effect sizes remained small (d=0.40, d=0.28, respectively). Punctuality

showed a medium effect size increase from pre to post (d=0.53) and a small increase

between pre and follow-up (d=0.32). There were no significant differences between means

or significant linear trends over time.

On closer inspection, both punctuality and attendance across time-points remained very low.

Punctuality, as measured by number of half-days late, showed a mean increase of less than 1

half-day, and mean number of days absent did not exceed 2. Figure 6 and table 6 displays a

detailed breakdown of absences, which show the majority of increase, particularly at follow

up, is due to temporary exclusions be that internal or external exclusion.

Pre Post 3-month_x000d

_F-up

0

1

2

3Breakdown of Attendance by Type of Absence

ExclusionUnauthorised AbsenceExplained Absence

Mea

n Da

ys A

bsen

t

Figure 6. Examination of type of absence

Table 6Type of AbsenceMeasure Pre Post 3 month F-up

Mean (SD) Mean (SD) Mean (SD)

Exclusion 0.00 (0.00) 0.47 (1.36) 1.47 (4.49)

Unauthorised Absence 0.07 (0.26) 0.27 (0.46) 0.23 (0.56)

93

Explained Absence 0.20 (0.46) 0.34 (0.82) 0.07 (0.26)

Total Absence 0.27 (0.50) 1.07 (2.05) 1.77 (5.24)

T-SDQ Outcomes.

Mean T-SDQ total difficulties (Goodman, 1997) reduced to near the clinical cut-off at post

and remained there at follow-up (figure 7). Small effect size reductions were seen from pre

to post (d= -0.39) and pre to follow-up (d= -0.29). However there were no significant

differences across means or linear trend over time.

Pre Post 3-month F-up10

11

12

13

14

15

T-SDQ: Total Difficulties

Clinical cut-off <12

Figure 7. Total difficulties

The Emotional Problems subscale (Goodman, 1997) showed gradual reduction in mean

scores at each time-point (figure 8), additionally means remained below clinical cut-off and

thus in the ‘normal’ range throughout. RM-ANOVA’s found significant differences between

means across time-points, F (2, 13)=4.367, p=.04. Significance was maintained on Friedman’s

non-parametric test, X2 (2, n=15) = 7.625, p=.02, indicating robustness of the parametric

finding. Bonferroni post-hoc comparisons indicated that follow-up mean was significantly

lower than pre. As with penalty points, there was not a significant difference between pre

94

and post scores, however there was a significant declining linear trend over time, F (2,

12)=8.308, p=.01.

Pre Post 3-month F-up0

1

2

3

4

5

T-SDQ: Emotional Problems

Mea

n Sc

ore

Figure 8. T-SDQ emotional problems subscale

The hyperactivity/inattention problem subscale mean reduced into the ‘normal’ range at

post showing small effect size reduction from pre to post (d=-0.44), which increased slightly

at follow-up but remained in the non-clinical range (figure 9).

Pre Post 3-month F-up3

4

5

6

7

T-SDQ: Hyperactivity / Inattention

Mea

n Sc

ore

Clinical cut-off <6

Figure 9. T-SDQ Hyperactivity or Inattention problems subscale

95

The remaining problem subscales of the T-SDQ (Goodman, 1997); conduct and peer

problems; did not show significant difference between means or trends over time, and effect

sizes of change were negligible.

Pre Post 3-month F-up0

1

2

3

4

5

6

T-SDQ: Pro-social Behaviour

Mea

n Sc

ore

Clinical cut-off >5

Figure 10. T-SDQ pro-social behaviour subscale

A similar pattern to reward points was noted in another measure of positive behaviour, the

T-SDQ pro-social behaviour subscale (Goodman, 1997). Initially a small effect size increase

from pre to post intervention (d=0.25) was observed, in line with initial hypotheses.

However change from pre to follow-up showed a small effect size decrease (d=-0.22),

indicative of deterioration at follow-up (figure 10). RM-ANOVA’s showed a significant

difference between time-points, F (2, 13)=3.988, p=.05. However the significant difference

did not hold for non-parametric Friedman’s test, X2 (2, n=15) = 4.596, p=.10. Due to the

questionable robustness of this finding, post hoc test were not completed.

96

Proportions of Reliable and Clinically Significant Change.

Table 7 shows the number and proportions of participants who achieved reliable

improvement; reliable improvement which fell below the clinical cut-off score; and reliable

change in a negative direction, indicating deterioration. Change was examined between pre–

post, and pre–follow-up scores. The number and proportion of participants whose scores fell

within ‘normal’ ranges at pre- interventions are also detailed in table 7. Appendix 9 shows

scores for each boy individually.

Table 7

Proportions of Reliable Change, Clinically Significant Change and below clinical cut-off pre-scores

RCI improve RCI improve& CSC

RCIDeteriorate

Pre score in 'normal' range

n % n % n % N %

Total Difficulties Post 4 27 3 20 1 7 4 27

FU 5 33 3 20 3 20

Emotional Problems Post 1 7 1 7 0 0 11 73

FU 1 7 1 7 0 0

Hyperactivity Problems Post 6 40 6 40 0 0 5 33

FU 6 40 6 40 3 20

Conduct Problems Post 2 13 1 7 4 27 7 47

FU 1 7 1 7 3 20

Peer Problems Post 1 7 1 7 1 7 11 73

FU 1 7 1 7 0 0

Pro-social Post 3 20 3 20 0 0 6 40

FU 1 7 1 7 0 0

Despite emotional problems showing a significant decline from pre to follow up, only 1 boy

made reliable and clinically significant changes. This may be explained by the high proportion

of participants (n=11) who scored within the ‘normal’ range at pre time-point. Interestingly a

sizable proportion (n=6) made reliable change and scores moved into the normal range in

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the hyperactivity problems subscale, however at follow-up 3 also showed reliable

deteriorations. Peer problems remained in the ‘normal’ range at pre time-point for 11 of the

participants. Interestingly there was little movement on the conduct problems subscale with

only 1 boy making clinically significant change at post and follow up, whilst a number of boys

(post=4, follow-up=3) made reliable deterioration on this subscale, however almost half

started in the non-clinical range at pre. Initial gains by 3 participants at post on the pro-social

subscale were only maintained at follow up by 1 participant.

Summary of Quantitative results.

In summary, penalty points and emotional symptoms were responsive to change following

attendance at the ACT group. However these were the only comparisons where the pattern

over time was distinguishable from sampling variation. The positive behavioural outcome

measures, pro-social T-SDQ (Goodman, 1997) and school awarded reward points showed

slight non-significant increases post intervention, but little longer-term change. Misaligned

with hypotheses, attendance and punctuality increased post intervention, however overall

numbers remained close to zero and most increase can be explained by a small number of

participants who were excluded. Whilst some reliable and clinically significant changes were

observed, many boys’ baseline scores began in the non-clinical ranges on the T-SDQ

(Goodman, 1997) which may account for these findings. Hyperactivity subscale showed the

greatest proportion of CSC, however this scale also showed 3 reliable deteriorations at

follow-up. Unexpectedly, conduct problems subscale showed little change and higher

proportions of reliable deterioration compared to improvements.

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Part 2 – Qualitative Thematic Analysis Of Effectiveness

Thematic analysis of post and follow-up teacher interviews delivered four inter-related

themes, which impacted the teachers’ perception of the extent of change in the boys’

behaviour and conduct in school. See table 8 for example quotes

Four inter-related themes were:

1. Ownership

2. Reflection

3. Perceptions and Reciprocity

4. Beyond the Group

1. Ownership - The teachers described positive changes in the boys’ conduct in school

emerging as they observed the participants beginning to take ownership over their actions.

They identified positive interpersonal behaviours including owning up when disciplined,

accepting the sanction, being less verbally and behaviourally reactive, communicating their

needs by asking for help from teachers, or having appropriate discussions about problems. A

lack of movement towards taking ownership for their actions, resulted in the teachers

witnessing continued problems such as, being untruthful, rude or overfamiliar with staff,

expressing a sense of injustice following a sanction, unwillingness to accept responsibility,

internalising difficulties and not communicating needs to teachers. See table 8 for example

quotes.

2. Reflection – Linked to the theme of ‘ownership’, the teachers also observed the

participants were being more reflective and thinking before reacting. At times they were

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witnessed to still behave in an undesired way, however the teachers perceived a shift in the

thought process used to determine their actions.

3. Perceptions and Reciprocity – The teachers highlighted the impact of how the boys,

teachers and ACT group were perceived, and reciprocal nature of the patterns of the

interaction emerging from these perceptions. The teachers described how initial perceptions

of the group affected how the participants’ responded to the group. For example they spoke

of some participants having a positive perception of being selected for the group; feeling

special or offering a sense of belonging, whilst another boy perceived inclusion within the

group as labelling. Implying that this personal orientation affected how well the boys

engaged with the group. Similarly the participants’ and teachers perceptions of one another

had an impact upon the quality of this relationship. The teachers described how these

perceptions generated reciprocal interpersonal patterns, which could become self-

perpetuating. This relationship could effect motivation, exacerbate problems or augment

change. Positive relationships based on praise were motivating, however misunderstandings

of behaviours lead to further problems.

4. Beyond the Group - This final theme describes the teachers’ holding a longer-term

perspective of change and commenting upon multiple influences outside of the group, which

were also impacting upon the boys’ behaviour. The teachers noted gradual maturation of

change punctuating across the school career, and

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Table 8

Example Quotes for Themes of Effectiveness

Theme Example Quotes

Ownership He does seem to be less defensive, less argumentative, which he wasn’t before, in terms of, so that’s, that’s a positive (teacher 1 re. adolescent participant 1)

and he’s very good at telling you now what’s wrong, he would never be a student that would come and tell you, “Miss, in English this happened” but now he will, he will really come and say “Miss I don’t wanna get in trouble” and you’ll be like that, “right okay, tell me what you did, tell me what they did, and let’s deal with it” (teacher 2 re. adolescent participant 15)Far less argumentative, far less, um reactive, if you like. So he, he won’t explode, he’ll think, he’ll wait for you to say what you have to say, and then if he can, he’ll ask can I can I share my, my opinions and then he’ll, he’ll go from there. Obviously at times he’ll go back to his previous state but, definite yeah I’m really impressed with <name> (teacher 1 re. adolescent participant 6).

he is a student that feels very unjust about things and that’s where he doesn’t learn to take his responsibility, so he ends up feeling like, “but why but why” (teacher 2 re. adolescent participant 7)

then his exclusion actually extended because he didn’t show any remorse at the integration meeting, which I felt that if you’re not showing remorse, then the sanction hasn’t bought home the fact that you’ve done something wrong. So then he further went to another five days. (teacher 2 re. adolescent participant 10)

He doesn’t take ownership yeah no and that’s the worst, the worst bit about it yeah. Fine be in trouble but, do the wrong thing, but take the responsibility for it when you’ve been caught and he can’t stomach that.(teacher 1 re. adolescent participant 4)

he just doesn’t communicate I find it such a struggle to communicate, but within lessons he doesn’t stop communicating in the wrong way, towards teachers (teacher 2 re. adolescent participant 13)

Reflecting Umm yeah he will, so he won’t just react, he will think about it and he will, he will respond in a calmer manner but he will still continue with what ever is that he’s doing (teacher 1 re. adolescent participant 2)

He will sit and reflect and before he opens his mouth. He didn’t have an off switch, and he wouldn’t be able to control his, whatever it is, that he was doing it would just come out and he’d become very anxious and very frustrated if he wouldn’t get his way. (teacher 1 re. adolescent participant 6)Little bit more um, yeah a little bit more reflective, and won’t necessarily be as, as negative towards the member of staff. he’ll take his punishment, from what I’ve seen, yeah he will just be, will think about his actions before he actually says anything. (teacher 2 re. adolescent participant 8)

Table 8 (continued)

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Example Quotes for Themes of Effectiveness

Perceptions and Reciprocity

That he was with the group, he wanted to go every week, he was like, “I’ve got my group, I’ve got my group, I’ve got to go to my group,” um and I don’t think, which was quite nice, is that he didn’t see it as, not that it was a punishment, but he didn’t see it was because of his behaviour that he got put in there, he was like, “this is my group”. Which was really nice so I thought that was quite positive. (teacher 2 re. adolescent participant 15)

I think for him any additional support he welcomes because it makes him feel quite special, um, so the group will have quite a knock-on effect with him for different reasons and being picked, being able to be out of the big circle and maybe be able to show his…(teacher 1 re. adolescent participant 12)

even with the start of the group he didn’t want to do the group because he felt he’d been labelled and I had to explain it’s not about that, don’t always think that everything is so negative or, you know it’s something to help you develop because how you’ve reacted in the past (teacher 2 re. adolescent participant 5)

…they can present themselves in a manner that they don’t necessarily think is wrong, so kissing their teeth, to them might not be an issue, but it’s the equivalent of swearing to somebody, but they don’t always connect that, um rolling the eyes, walking around like with a, real screw face. They don’t necessarily know that they’re doing it, and so the teacher is reading that information and seeing it is negative, and when confronted about it the kids sometimes get defensive because they don’t necessarily know what it is that they’re doing so then they feel like they’re being picked on and then you have this endless carousel and if you’ve got new members of staff, who don’t know the students yet, they are going to follow the procedures in the sense that, ‘well you didn’t do this, so it’s a <penalty> point’ before they actually talk to the student about it, so then they can become quite frustrated. (teacher 1 general)

And when I see him in lessons…I walk over and he’ll talk to me about his work, so he seeing me in a different light, I’m not just there being negative, like we’re talking about positive things and yeah no it’s definitely helping. (teacher 2 re. adolescent participant 6)

so he is an absolute joy student who you just want to give everything you can, just so that he never slips back. (teacher 2 re. adolescent participant 15)

teachers are still frustrated with him, he will stand there and argue with people, (teacher 1 re. adolescent participant 11)

Beyond the group

Umm, A combination, I think his mum is very strict and um, so when we get on the phone to her um, that means he’s gonna be in trouble, um… but he’s been on report to us, he’s doing this project, or has done this project with you, (teacher 2 re. adolescent participant 13)

Um, he has some SEN need and we are in the process of putting an education plan for him just to find out what support he actually needs from us, and how we can help him further, but there has been a definite, definite improvement in him. (teacher 1 re. adolescent participant 9)

Table 8 (continued)

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Example Quotes for Themes of Effectiveness

Beyond the group (continued)

yeah so it fluctuates, for him it’s up-and-down and to be honest he struggles more in a double lesson he finds that very difficult and gets bored very quickly, I mean two hours of siting down focusing is hard for anybody but he will start to act up when he’s bored (teacher 1 re. adolescent participant 10)

so with what you’ve done, with that, with like the meetings that we’ve had, yeah there has been some improvement. (teacher 2 re. adolescent participant 1)

The way he reacts he seems he seems to have calmed down and what we’re, we’re trying a new tactic now with him where we’re giving him more responsibility, so if we need resources to be handed out amongst the learning leads, we’ll get him to do things, just so that he’s a pro active member of the < school > team (teacher 1 re. adolescent participant 9)

there was a thing with homework, so mum expressed that with me, that she hasn’t got a laptop at home she doesn’t have a tablet, so sometimes he can’t always access, what he needs from the tablet so I’ve allowed him to come into a homework club, um, which I haven’t been in, so I’m not sure if he’s attended but we gave him that option, because I know some of his <penalty> points was most definitely down to homework, so we try to rectify that for him. (adolescent participant 3)

He has calmed down an awful lot, he’s still not perfect, um but, he’s definitely trying and you can definitely see a change in him.…made so much progress since year eight... (adolescent participant 6)

He has calmed himself down, a lot, but he’s still got a bit about a bit of the journey to go on. (adolescent participant 9)

I think it’s been a consistent progression from the beginning of the year (adolescent participant 14)

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compared the boys’ current presentation with previous behaviours from earlier years. They

also made reference to multiple additional influences, beyond the group, that impacted

upon the participants’ conduct in school. Including concentration difficulties, additional

learning needs, parenting styles, social deprivation, changes in teacher’s/school’s approach.

Overall this theme highlights that teachers saw the ACT group as a moment in time, which

may have facilitated the participants’ development and along with other influences, any

changes were to be integrated into their broader developing selves.

Part 3 – Feasibility

Delivery of the ACT Group - Feasibility Constraints

Fidelity to the protocol suffered, as there were a number of changes to the planned delivery

of the group due to feasibility issues within the school. Systemic issues impacted; the

pastoral care teacher left the school just before commencement of the ACT group, so there

was an interim co-facilitator for group 1 and the new member of pastoral staff co-facilitated

groups 2 and 3. The weekly between-session homework and mindfulness practice carried

out by the school co-facilitator did not occur as planned due to time constraints of the two

co-facilitators. This only took place for groups 2 and 3, once a week on a few occasions.

Owing to practical constraints resulting from timetabling issues, the content for the second

group had to be condensed into 4 sessions, the first being a longer 2-hour session.

Qualitative: Thematic Analysis of Feasibility

An embedded thematic analysis of feasibility interviews with school staff uncovered one

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overarching theme of, ‘Embedding’ which had four subthemes, ‘logistics’, ‘engagement’,

‘facilitation’ and ‘duration’. The overarching theme encapsulates the main feasibility issue

that came out of the interviews, namely that for the group to run efficiently it must be

embedded within the school system. See table 9 for quotes relating to each theme.

a. Logistics describes a number of logistical barriers that the teachers foresaw before the

commencement of the group, and other unexpected logistical issues. These included staff

capacity; staff timetables were already at full capacity and so any additional work exceeded

this; although rooms were pre-booked, double booking occurred. Similarly the group times

were not embedded into staff and student timetables, which required the co-facilitator to

collect a number of the boys from class. Although staff were in agreement that a non-core

lesson was best for the group, one person highlighted that the participants at times did not

want to miss this lesson. Embedding the group into the usual timetable would mean that the

participants may not feel they were missing out on other educational opportunities.

b. Engagement Staff highlighted the importance of engaging the participants in the purpose

and activities of the group. That there needs to be a level of buy-in from the boys and they

need to see the benefits for them, whilst minimising stigma. To support engagement the

students need to see the study team as a long-standing part of the school.

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Table 9

Example Quotes for Feasibility Theme and Sub-theme

Theme Subtheme Example Quotes

Embedding Logistics I think there’s the element of the organisation and the communication in the business of a school day, and you know thing happen with rooms and staffing members and people aren’t in and you know thing happen, kind of that additional, at one stage it’s an additional pressure

one thing I did find actually, is that sometimes the pupils wouldn’t want to come because it would be a <name of lesson>, so sometimes they’d be like, “ah we really wanna go to our <name of lesson>, it’s really important” So sometimes their classes may… so that the tricky part… fitting with my <co-facilitator’s> timetable, their <boy’s> timetable, all of the timetables.

Engagement Provided they get the buy in, because obviously it’s all about how it’s been marketed, how it’s being sold to the students

I think it’s always difficult, especially when doing a study / pilot, to be perceived by the young people as part of the school.

…the young people see you as someone who is long term and it’s not some sort of one off intervention or a short time, it’s that this is going to be revisited if you don’t make the change … this person is going to have a relationship and they’re going to track your progress

I think it will fit in better here than, as you said them going to a centre, ‘cause it’ll be more like therapy and will have a little bit of stigma attached to it, in this format it’s better.

<Discussing homework> Yeah I think if they’re fun tasks and you know you get them to write in their planners before they go.

Facilitation Could you envisage running the groups without the study team?Yeah I think we could envisage…Yeah I think so I think as long as the people are confident in running the groups.

…the way you set up the group, so you know, putting the ground rules and not coming as an authoritative figure but rather a figure of let’s look at this, lets, in here it’s ok to look at our anger and explore it and see where it’s coming from or how to deal with it, I thought that was really important

I think it’s a big big difference, there were certain times where I <cofacilitator> wanted to butt in, I held back whereas teachers wouldn’t be aware of those types of things, having psychological mindedness and need for pauses

Duration I definitely think there is something that would benefit the students definitely long term doing short workshops and then not really revisiting not really doing those workshops again I feel that sometimes over time that they are just going to forget about it over time, and then all that hard work could potentially be wasted. so if you did have somebody within the school contact who met with the students throughout an entire year then yes it would go into the long-term memory but 4, 5, 6 weeks it was staying their short-term memory and then be forgotten about

Timeframes, is that a suitable timeframe to try and address their problems or their issues, like anger management, or is it something that’s much more long term? Or is it too late in year 9, is it something that should be addressed earlier, and all these different things. Because it’s not just going to be a fix after going to one session or 6 sessions I guess.

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c. Facilitation A spectrum of views were raised about facilitators of future groups. Some staff

felt that with the right training, on-going management and supervision, staff could facilitate

future groups; whilst others highlighted the benefits of external, non-teaching staff.

Specifically they mentioned the differences between authoritarian, didactic standpoint

which teachers may be familiar with compared with a more collaborative facilitation that

pastoral staff with therapeutic backgrounds may hold.

d. Duration the staff commented on the brief duration of the intervention. In order to

embed the intervention within the school staff felt that the participants needed to see

facilitators as belonging to the school, for example, therapists holding substantive posts

within the school. Additionally they suggested that on-going sessions or boosters would help

to practice the skills on a more regular frequency and embed the skills into their usual school

day.

D ISCUSSION

The current study aimed to assess a school’s perspective of the effectiveness of the ‘Taking

ACTion on Anger’, an ACT intervention for adolescent boys. The qualitative and quantitative

findings will be discussed alongside an exploration of connections between them to provide

a greater understanding of effectiveness.

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Triangulation of Main Quantitative and Qualitative Findings

The analysis of quantitative data established two positive significant changes; these were

declines in school penalties and the teacher’s scores on the emotional problems subscale of

the T-SDQ (Goodman, 1997). Although both showed significant decreases from pre to 3-

month follow-up, changes began to emerge immediately after the group, as evident by a

downward trend across time-points. The significant changes occurring 3 months after the

intervention could signify that the boys were benefiting from time to consolidate their

understanding and utilising the skills delivered in the group. Additionally, the ‘beyond the

group’ theme drawn out from the informant teacher interviews also offers support and

further insight into the change process for the participants. It may be that that teachers

expect a more gradual process which is part of the typical developmental learning style of

these boys. Kolb’s (1984) learning cycle describes learning being gained through experience;

in line with Kolb’s theory, the participants may have needed to experience, and reflect on

new ways of thinking and behaving before longer term integration could occur. Alternatively

it could be a reflection that teachers are involved with the boys throughout their school

career and expect developmental progression across this time frame. Moreover this theme

implied that the teachers viewed the group as acting as a catalyst for change in some of the

participants, at times in combination with extraneous factors outside of the group, including

parental influence, additional learning support or needs. This catalyst effect could also

explain greater change at follow-up.

The qualitative and quantitative findings highlight the importance of selected an appropriate

timeframe for evaluation. The initial study design considered immediate and post 3 months

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to be reasonable indicators for success, whilst the teachers interviewed provide a context for

change being slower. The feasibility sub-theme, ‘duration’, where school staff commented

on the short duration of the group, and suggested expanding the group to include additional

sessions, taking place over a longer time period or including booster sessions, also highlights

a misalignment of the researchers and teachers timeframes. Thus any evaluation going

forwards needs to have a more protracted follow up period. A longer duration of the group,

plus booster sessions also fits with the growth and development mind-set of young people,

who need to experience new changes prior to being able to consolidate these new way of

responding and behaving (Kolb, 1984).

The drop in penalties given by various teachers immediately after the group with a further

decline at 3 months is a very positive change, as it is indicative of a number of teachers

noting observable changes in the boy’s conduct. During the informant teacher interviews it

was not only behaviours that were observed to change, but also of subtle changes in the

boys which provided teachers with a sense that some boys were taking ‘ownership’ over

their behaviours and appearing to think about or ‘reflecting’ on their response before acting.

Emerging from the teachers’ qualitative data, the theme of ‘ownership’ for the participants

conduct appears to map onto the ACT concepts of ‘values’ and ‘committed action’, (Harris,

2009). These were explored within the Taking ACTion on Anger group through metaphors

and choice-points, where the participants were told that the facilitators would not tell them

how to act, instead encouraged them to make their value-driven choices. The teachers

described changes where some of the boys began to take ownership over their actions and

actively took responsibility for seeking help. In ACT theory, ‘values’ are seen as the compass

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to guide ones actions, whilst ‘committed action’ is about doing what is necessary to achieve

goals that are in line with ones values (Harris, 2009).

The theme of ‘reflecting’ noted that the teachers observed the participants pausing and

thinking before reacting. As the teachers were commenting on their observations of the

boys and reports from other teachers, the participants’ internal experiences cannot be truly

known. However it could be hypothesised that this theme could be linked to number of ACT

concepts. Including, ‘contact with the present moment’, that is an awareness of what is

happening in their internal world, ‘acceptance’, which is opening up to difficult thoughts,

feelings or urges, and even ‘defusion’ which is stepping back from difficult internal

experiences. These ACT concepts are theorised to deliver psychological flexibility which may

have allowed the boys to make choices in line with their values and linked to the ‘choice-

point’ metaphor used in the group (see appendix 7 for intervention protocol).

Importantly, although there was a drop in penalty points the participants were still receiving

penalties and teacher interviews observed not all of the participants showed change in their

conduct within the school environment. Similarly, the conduct problems subscale of the T-

SDQ (Goodman, 1997) showed little change across time. The teachers commented that

although some boys appeared to be reflecting, which allowed them to be less reactive and

make what the teachers perceived as more appropriate choices, others did not always

choose to act in line with the schools expectations of appropriate conduct.

The significant change scores on the emotional subscale do suggest that the boys were

making internal changes. Whilst the scores were within the non-clinical range this does not

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detract from the benefits accrued, and suggests that the ACT intervention can address the

needs of young people as well as having a possible preventative role.

From the vantage point of the teachers the need to address the externalising or disruptive

behaviours was crucial. The group was able to support some of the participants to alter their

impulsive behaviours captured within the hyperactivity scale, with the teachers reporting a

number of the participants moving from the clinical to normal range of responses. The

conduct problems subscale however failed to show clinically significant change, and a

number of boys on this subscale made reliably detrimental change.

Interestingly both reward points and pro-social T-SDQ subscale (Goodman, 1997) showed

slight increases immediately after the group, which were not maintained or built upon at

follow-up, indicating that the intervention had little sustained impact upon these measures.

Previous studies using the T-SDQ (Goodman, 1997) have found low correlations between the

pro-social subscale and problem subscales (Van Roy, Veenstra, Clench-Aas, 2008) which

supports Goodman’s (1997, p. 582) explanation that, “the absence of pro-social behaviour is

conceptually different from the presence of psychological difficulties”. Perhaps specific

interventions are required which target more pro-social or school reward generating

behaviours, which was beyond the scope of this current brief intervention.

Increases in measures of attendance and punctuality were not in line with initial hypotheses,

however scores remained close to zero, indicating that these measures may not be sensitive

enough to detect change. Additionally this data was skewed by the high proportion of

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exclusions for a small selection of participants. This does further corroborate the severity of

behavioural difficulties associated with a small proportion of these participants, suggesting

that these particular boys may have been beyond the emerging difficulties remit of the

study. Future research would benefit from the school receiving additional guidance and

support from the researchers when selecting the adolescent participants.

The theme of perceptions and reciprocity highlights an important interaction between how

perceptions of the participants, teachers or group, can generate positive or detrimental

patterns of behaviour. The theme indicates how the reciprocal relationship between

teachers and students, could result in self-fulfilling prophecy (Rosenthal & Jacobson, 1968).

It also gives some indication of how a pattern of persistent disruptive behaviour may

develop. For example if teachers have negative expectations of the boys, they may be

looking for problems and expect to deliver penalties, the boys in return view the teacher as

penalising them, causing them to behave differently and result in poor teacher-pupil

relationships, which become self-perpetuating and may ultimately result in school exclusion.

Equally positive perceptions such as the boys or teachers are trying, making an effort may

have a self-perpetuating impact in a positive direction. It is also possible that through

participating in the teacher interviews, this may have impacted upon the informant teacher’s

perceptions of the participants who attended the group. Research has highlighted the

influence of teacher-student perceptions. For example students holding negative

perceptions of their teacher’s interpersonal behaviour has been linked to poorer educational

outcomes (den Brok, Brekelmans & Wubbels, 2004). Systems theory has been suggested to

support teachers working with young people with emotional and behavioural problems,

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(Souter, 2001). Ideas such as locating the problem within the system rather than the

student, reframing the problem behaviour (Murphy, 1992), all assist to alter the teacher’s

perception of the student.

The subtheme of ‘facilitation’ within the overarching ‘embedding’ theme found in the

feasibility data raised an interesting debate around whether teachers, pastoral care staff or

trained therapists, are best placed to facilitate the groups. One cluster randomised control

trial used teachers to deliver a 3-session preventative ACT intervention to students and

found no effect for the treatment condition compared to wait-list (Van der Gucht et al.,

2017). The authors identified the competence and motivation of the teacher facilitators as a

key issue and recommend using professionally trained therapists in future. However further

research is need to enquire whether with appropriate supervision and checks of

competence, teachers could deliver such interventions.

Strengths and Limitations

The study’s key strength was that it was set in a naturalistic school environment, thus

offering a realistic picture of the benefits and possible pitfalls of delivering this type of

intervention in a school setting. A further strength is its demonstration of making ACT

concepts accessible to adolescent males, which enabled the participants to grasp the

concepts, engage with the approach and to effect change in their school conduct as

observed by the teachers. The two informant teachers were in critical roles for receiving

behavioural information from numerous members of staff. Although with greater resources

more perspectives would have been sought, these teachers were best placed for this role

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given the resource limitations. The study also identified the challenge in being able to be

faithful to the programme protocol and highlighted feasibility adaptations for effective

school based interventions. Overall this feasibility study showed promise for using ACT

applied to anger with adolescent boys.

There were various methodological limitations. The small sample size does limit the

interpretability of the results, however this was known at the outset. Unfortunately fidelity

to protocol was poor due to feasibility issues and school delivery barriers, however this in

itself provides information on the challenges of delivering this intervention in a school

setting. The impact of fidelity issues were considerable. Namely different co-facilitators,

condensed sessions, a lack of homework, and sporadic between-session mindfulness

practices, meant that not all groups received the identical intervention. Future studies would

need to discuss the logistics of these elements of the programme with the school hierarchy

to ensure identical delivery and the ‘dose’ [number of sessions and any additional support],

of the intervention. Furthermore, feasibility data suggests that future studies would need to

embed interventions into pre-existing school systems, over a longer period. Another

limitation is missing data for non-completers; data collection needs to be considered

carefully in future studies to capture the data at the outset and throughout the process.

Furthermore, comparison of pre data for completers and non-completers is recommended.

The study design would have benefitted from the teacher interviews being conducted by an

external interviewer to reduce the possibility of interviewer bias, which was not possible due

to the limited study budget. Additionally only two informant teachers were included in the

interviews, limiting the number of different perspectives. Fewer informants were balanced

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with school penalty and reward information, given by all teaching staff throughout school, to

manage the potential bias of having only two informants. Validation of the themes

generated was achieved through discussions with the research supervisor. Future studies

could improve the quality checking procedure by using peer validation or keeping a

reflective log.

Future Directions

The ‘Taking ACTion on Anger’ group needs to be re-run addressing the feasibility issues

around fidelity to the protocol. In line with the feasibility interview findings the group should

be embedded into the school environment, over a longer duration. If this proves positive, a

larger scale study needs to be commissioned to examine influence of other factors such as

additional learning needs, being involved in other interventions, and the impact of these

factors on the findings.

To embed ‘Taking ACTion on Anger’ within the school, the intervention should be inserted

into staff, student and school facilities timetables. The study team should invest more time

at the outset to promote the project and assist with identification of participants; increased

knowledge of the group may instil hope in staff that the intervention may effect change. The

intervention should include additional top-up sessions, throughout the school career; to

ensure skills are practiced in relation to lived experiences.

The benefits offered by the boys and teachers holding a positive or hopeful perception of

one another, and of the group itself offer avenues for future research incorporating a

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teacher aspect to the intervention. This complimentary group could intervene from an

organisational and interpersonal systems perspective.

The small number of participants whose difficulties may have been above the ‘emerging

difficulties’ remit, highlights a more general challenge of providing a specific intervention

within a school environment for young people that may have a wide range of difficulties. It

suggests that more stringent inclusion criteria or assessment processes may be helpful.

However, as the feasibility data suggests that the intervention should be more embedded

into school systems and environment, it may be more helpful to approach future school

interventions using a stepped care approach. ACT is a transdiagnostic model, making it very

suitable for a range of difficulties experienced by adolescents. Future groups could maintain

their male focus, but instead offer a briefer psycho-educational and skills group covering a

range of difficult emotions. Briefer 5 sessions could be offered to adolescents requiring

preventative interventions, with a more traditional 12-session group for adolescents who

require a more intensive support. Additional top-up sessions for all group attendees with the

inclusion of teachers at specific sessions to embed the learning across the school

environment.

Clinical Implications

Although the application of ACT adolescents is in it’s infancy compared to traditional CBT,

this study offers promising results for adapting ACT to the needs of adolescents. In addition

to making a promising contribution to the literature for adolescent anger interventions, and

school-based interventions. Moreover, currently there are no published intervention studies

applying ACT to British adolescents, within the field of emotional well-being. As such, this

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study is an early addition to the UK evidence base for ACT with adolescents.

The current study evaluated change from the teachers’ and school viewpoint; in doing so it

demonstrated the benefits of using an alternative perspective change, which is often

overlooked in the literature. This perspective offered a number of new insights into

delivering interventions within a school setting; namely, the importance of a longer

timeframe for intervention, including booster sessions to directly apply the intervention to

real-life experiences. It also highlighted the importance of the intervention being perceived

as an integrated part of the school, including embedding interventions within pre-existing

school systems. The study emphasised the importance of the teachers’ perspectives of the

participants, and the reciprocal influence change in either teacher or student perspectives

can have on resulting behaviour. This finding opens up new opportunities for intervention

with teachers to help address problem behaviour in young people.

CONCLUSION

In conclusion, the development of the Taking ACTion on Anger intervention, based on the

ACT Hexaflex has proven to be accessible and useful for adolescent boys. Despite feasibility

issues and incomplete fidelity to the protocol, in this small sample the intervention has

shown promise for improving staff observed school conduct in the participants. The largest

gains were found 3 months after the intervention, indicating that the participants may

require time to consolidate the information. Teachers observed the boys reflecting and

taking greater ownership over behaviour; changes, which appear to map onto key ACT

concepts. Feasibility interviews highlight the need for future school based interventions to

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be fully embedded within the school environment. Additionally teacher awareness of the

group and engagement in the process may have added reciprocal benefits for the boys

involved. Future studies may consider an additional teacher intervention taking an

organisational and interpersonal systems perspective.

118

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MRP EMPIRICAL PAPER APPENDICES Page

Appendix 1 Ethical Approval 125

Appendix 2 Information and Consent Forms 126-135

Appendix 2a Teacher Information Sheet 126

Appendix 2b Teacher Consent Form 128

Appendix 2c Adolescent Participant Information Sheet 129

Appendix 2d Adolescent Participant Consent Form 132

Appendix 3 Information Letter to Parents 133

Appendix 4 Teacher Strengths and Difficulties Scale (T-SDQ) 135

Appendix 5 Interview Schedules 136-139

Appendix 5a Pre Study Feasibility Interview Schedule 136

Appendix 5b Post Study Feasibility Interview Schedule 137

Appendix 5c Informant Teacher Post Intervention Interview Schedule with Feasibility Questions

138

Appendix 5d Informant Teacher Follow-Up Intervention Interview Schedule

139

Appendix 5e Informant Teacher Post study Feasibility Questions 139

Appendix 6 Intervention Protocol 140

Appendix 7 Histograms Examining the Distribution of data 151

Appendix 8 Raw Scores of Reliable and Clinically Significant Change for Adolescent Participants

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Appendix 9 Example extracted codes from effectiveness interviews 159

Appendix 10 Example extracted codes from feasibility interviews 162

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Appendix 1 - Ethical Approval

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Appendix 2 - Information and Consent Forms

Appendix 2a - Teacher Information Sheet

130

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Appendix 2b - Teacher Consent Form

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Appendix 2c – Adolescent Participant Information Sheet

133

134

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Appendix 2d – Adolescent Participant Consent Form

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Appendix 3 – Information Letter to Parents

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138

139

Appendix 4 - Teacher Strengths and Difficulties Scale (T-SDQ)

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Appendix 5 - Interview Schedules

Appendix 5a - Pre Study Feasibility Interview Schedule

141

Appendix 5b - Post Study Feasibility Interview Schedule

142

Appendix 5c - Informant Teacher Post Intervention Interview Schedule

143

Appendix 5d - Informant Teacher Follow-Up Intervention Interview Schedule

Appendix 5e - Informant Teacher Post Study Feasibility Questions

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Appendix 6 – Intervention Protocol

Session ObjectivesSession 1.Chilling with your tiger: For warriors, not zombies

1.5 hours in duration to allow time for questionnaires

Get to know each otherPsychoed/mythbustingIntroduce ACT for Anger and basic principles of ACTIntroduce MindfulnessHomework – what have they tried in the past

Activity ACT Principle Duration Resources

Questionnaires and mirror tracing task 30 mins Questionnaires, computers, pencils

Introducing our role Open with – we’re not here to tell you what to do. Introduce choices – the main theme of these workshops is

about choices. What we hope you will take from these workshops is a new set of skills to enable you to make choices about your life.

Why they are here - teachers think anger / reactions might be getting in the way of their values, where they want to go in life

You get out what you put in

5 mins Powerpoint

Workbook section to complete on role models

Introduce each other Introductions – say your name, and name of someone who inspires you, could be someone you know / celebrity.

Name 3 things about that person that you find inspiring. Facilitators to do their own examples

Values 15 mins Include space in workbook

Group Rules & CommitmentAsk young people first. Write on flip chart. Include the following if they don’t come up with them:Don’t talk over each other / Be respectful (include bad language) / Confidentiality / Phones off / Commitment. Include risk statement within confidentiality and leaving the group if they break it.Sign the rules & commitmentCommitment = to rules and doing homework and mindfulness practices in between.You are part of a research study - important role as you may be shaping future services.

10 mins Contract in workbook

Powerpoint group rules

Introduce anger / ACT – myth busting quizYoung people to complete workbook individually quickly, and then we go through Powerpoint with explanations below.

15 mins Buzzers

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Young people to buzz simultaneously if they think it’s a fact or a myth. Young people to explain their thoughts.Buzzers (10 seconds to test at start).Fact or myth 1: No one has ever got into trouble for feeling angry

Fact! Our thoughts and feelings don’t have power, our actions have power. They can seem very powerful, but we have a choice how to respond.

Introduce the idea of choice pointFact or myth 2: Venting your anger is healthy and helpful

Myth! Effect it has on you and effect it has on others Practicing angry response for future angry situations Anger will pass with time – not due to venting

Fact or myth 3: I can’t control myself when I get angry Fact/Myth...but really a myth. Right now, it might feel like you can’t control what you do when you get angry. We’d like to teach you strategies on how to choose your responses when you are feeling angry, so that you are in

control At the moment, what you are doing is fighting the “anger tiger”. Sometimes you might win if you catch him off

guard, often you’ll come away with scrapes and scars (detention, hurt feelings, telling off from parents). Instead what we would like to teach you is to “walk with the tiger”. Rather than battling with difficult feelings, if

you can learn to accept having them and walk with them, you can be much more in control of your life. You can walk with the tiger to what’s important to you (parties, family events, better education), rather than

being battered and bruised by him.Fact or myth 4: My anger is bad

Myth! We all experience anger, and a range of emotions – “good” and “bad” thoughts and feelings. Can feel painful, and it can feel like we want to get rid of them, and we therefore often get stuck in a battle with

them. E.g. “I’m feeling angry, therefore I must do something with this anger – shout/punch/swear/kick stuff over, etc.

The battle with the anger is what causes us the problems, rather than the anger itself. The tiger itself is not bad – it’s how we relate to the tiger.

So, how do we learn to walk with the tiger? We become wise warriors, rather than mindless zombies!Facilitators to explain metaphors as below.The wise warrior learns to accept his tiger, and walks with him towards what’s important. The alternative? A mindless zombie – responds to urges, attacks anything it sees, doesn’t know what it wants out of life, forever battling with the tiger and likely to end up with a lot of injuries along the way.

Defusion

Committed Action

Acceptance

Experiential avoidance(Dropping the struggle)

Powerpoint with myths/facts on them.

Powerpoint with zombies, wise warrior, and tiger images and key words about each one.

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Wise warrior: Notices difficult thoughts and feelings, but isn’t controlled by them. Willing to experience them, rather than get rid of them. Awareness that he is more than his thoughts and feelings. Knows what is important to him in life and pursues this.

Mindless Zombies: As soon as he feels something, he gets caught up and overwhelmed by it – whether that be hunger, fear, anger. No awareness of himself as anything other than something that responds to urges. Unwilling to feel difficult emotions (e.g. hungry, scared) so will respond as soon as he feels them. No awareness of what is important to him, so directionless (running around in circles).

Metaphors for all key ACT principles

Mindfulness task: One step towards becoming a wise warrior is to learn to observe what’s happening within you. We will be

practicing this in all of our sessions. Learning to slow down, notice what’s going on, notice our thoughts and feelings, all in the aim of choosing how to respond, rather than responding like a zombie

Really important part of the course - like learning a musical instrument. If you never practice, you won't develop the skills.

Present moment

Defusion

10 mins

Homework:

First: Say one thing you have learned today?Do first 3 columns for 3 examples over the past month. We will do the 4th column next week.

Attend mindfulness practice classes.

5 mins Homework summary on powerpoint and in workbook.

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Triggersomething someone says or does, situations e.g. getting a bad mark on homework

How I feltfrustrated, ashamed, guilty, stressed, afraid, controlled, disappointed, threatened, upset, embarrassed

What I didShouted, ignored, repressed angry feelings, punched something

What were the costs?relationships, school, health, energy emotional

In-between session mindfulness practice at school? NotesAs in session Give copy of mindfulness script to session facilitator

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Session ObjectivesSession 2Pursuing your values with courage and strength

Explore the following:Cost of acting on angerValuesChoice pointCommitted action

Activity ACT Principle

Duration

Resources

Mindfulness exercise – Mindfulness of body after doing exerciseDebrief – What did you notice? Where you able to observe your experience, rather than getting caught up in it?What do you remember from last week? – Recap main metaphors

Present momentDefusion

10 mins

Mindfulness script

Reviewing homework and completing 4th column - Costs of actions. Examples might be punching, shouting, swearing, storming off, slamming doors, breaking things, ignoring people.

Link back to fighting the tiger – each time they have done something to get rid of feeling angry/embarrassed/frustrated or acted out feeling angry, they have battled with the tiger. It is all an effort to avoid unwanted thoughts/feelings/physical sensations. Perhaps we can learn to accept the tiger and walk alongside him, rather than battle with him? Perhaps okay to have the angry tiger with us, but experience life with him rather than trying to get rid of him?

Experiential avoidance

Acceptance

15 mins

Workbook

Introducing values (and goals)What’s the point in learning to walk with your anger tiger? So that instead of getting into battles with him, you can focus your energy on what’s important to you in life. We call these things “values”. (See powerpoint/workbook for details).

Use analogy of football: Ronaldo - practising every day for the values of being committed, hard-working, challenging himself, being a good team player. Associated goal might be winning the Ballon D’Or, but Ronaldo is having a meaningful life every day as he is living by his values, whether he achieves the award or not.

Values versus goals exercise: Several individual cards with examples of values or goals listed on them. Participants to sort into piles of what are values and what are goals. Facilitators to summarise at the end:

Values are what are important and meaningful to you in life. They are what you want to stand for. They are

Values 20 mins

Powerpoint/ Workbook

Values v goals cards

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things you can always live by. They are different to “goals”. You can always work towards a value, you can never tick it off your list. A goal you can tick off once you’ve achieved it e.g. go to my friend’s party, make a million pounds, go to university, get married, etc. A value is something you can always be – e.g. being a supportive friend, being hard working, being a learner, being loving/caring, etc.

Exercise: 18th birthday speech. To help you to figure out what your values are, imagine you are at your 18 th

birthday party, and someone close to you is standing up to give a speech about you. What would you like them to say about you? What qualities would they say you had? If they were describing how you have lived your life so far, what do you want them to say?Note, you might want to look back at your role models from the first session – what did you admire about them that perhaps you would also like to stand for?

- NB If they see “be rich/handsome, etc, ask them how they would want to be described if they had achieved all of those things? What other things would they like people to say about them?

Do in pairs and feedback one value to group. Facilitators will walk round.

Complete section in workbook

Wise warrior vs mindless zombie: Pursuing your values with courage and strength. In the face of frustration, setbacks, failure, and resentment, can you pursue what’s important to you? This is tough, but if you can learn to mindfully observe your thoughts and feelings, rather than getting tangled up in them, it gives you more freedom to make choices.

Talk through biography of Lebron James (faced adversity and frustration but continues to pursue values)

Can you think of anyone else who has stayed true to their values, even when faced with adversity or anger-provoking situations?

Values

Psychological flexibility

5 mins

Powerpoint/ workbookLeBron James biographyPowerpoint collage of LeBron James experiencing difficult emotions & separate one of success.

Complete Valued Living Questionnaire (VLQ) 5 mins

VLQs

Homework taskFirst: Say one thing you have learned today?Set a value guided goal to complete for the following sessionValued Living Questionnaire (VLQ) if not time in lesson

5 mins

Workbook

Mindfulness practice at school NotesAs in session Give copy of script to session facilitator

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Session ObjectivesSession 3:The Anger Mask

Acceptance / Willingness to feel – difficult emotions / feelingsVideos to demonstrate complex emotions involved when people get angry and anger masking thisAwareness and acceptance of difficult emotionsIntroduce self as context

Activity ACT Principle Duration ResourcesMindfulness of MusicDebrief – What did you notice? Where you able to observe your experience, rather than getting caught up in it? Did you hear anything that you didn’t expect to, when you really paid attention?

Present moment

Defusion

10 mins Music clip: https://www.youtube.com/watch?v=eRCJow2tKsoMindfulness script

Recap of last week and review values homework – did they manage to complete their goal. If not, why not? Were the barriers internal or external?

ValuesCommitted action

10 mins

Anger masking difficult emotions:Video of Phil Mitchell being angry. Discuss what’s happening in pairs and feedback:

- What unwanted emotions are being masked by anger?- What emotions is he unwilling to experience here?- Refer to choice point – what choice could he have made differently? What would have been

more in line with his values?- Refer to zombie tiger battle versus wise warrior walking alongside the tiger

Group discussion- Refer back to week 1 homework task – what emotions do you find often might be being masked

by anger? (Facilitators may wish to self-disclose here if appropriate)- Summary: If we allow ourselves to experience these emotions – whether happy, sad, lonely,

frustrated, rejected, then we can choose how to respond and respond in line with what’s important to us. Alternative – mindless zombie – not thinking through responses, acting on impulse, often taking us away from our values (not many of us value hurting other people/not achieving at school, etc).

Acceptance / Willingness to feel

Choice over behavioural responses

Values

15 mins Videos of Phil Mitchellhttps://www.youtube.com/watch?v=Bt0m3VLnG34

Powerpoint of tiger/zombie and wise warrior with relevant characteristics superimposed.

Another metaphor.... Self-as- 5 mins Laminated pictures of

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Young people to get up and act out the sky and various parts of the weather.- Sky and the weather. Weather = thoughts and feelings. Sometimes difficult, sometimes

wonderful, but always pass. The sky is always present and will survive all types of weather unharmed. No matter how bad the weather gets, the sky cannot be harmed. The sky will accept all weathers. The sky is the part of you that is always present, that experiences all of your thoughts and feelings. This part of you also experiences them passing. Thoughts and feelings come and go, but the part of you that is like the sky, which experiences them and observes them, is always present.

- The task of the wise warrior is to be the "sky". Noticing and observing all weathers, and all thoughts and feelings, noticing them coming, and noticing them passing again. Rather than getting caught up in the storms. No matter how intense the thunderstorms get, the sky is always there.

context the sky, lightening, clouds, sun, etc.

What can help you to be the sky and learn to be with difficult feelings?Mindfully notice what you are thinking and feeling and separate from it via defusion.

Defusion exercises: Using “silly accents” to say normally angry thoughts, e.g. “He is winding me up on purpose – he’s taking me for a mug!”. Participants to practice this as a group.

Once you have done this – choice point, i.e. once you have separated from your angry thoughts, you can choose how to respond. You are now a wise warrior, rather than a mindless zombie.

Defusion 10 mins Accents: The queen, Mr T, whisper, Arnold Schwarzenegger, Simon Cowell, Keith Lemon, etc/

Complete Valued Living Questionnaire (VLQ) 5 mins VLQs

HomeworkFirst: Say one thing you have learned today?

- At some point over next week, mindfully listen to a genre of music which makes you experience a difficult feeling e.g. embarrassed, sad, upset, annoyed, angry - see if you can sit with it and observe your experience, thoughts, feelings, urges, rather than do something to get rid of it. Record in workbook.

- Practice defusion exercise. Record in workbook and read section in workbook.- Complete a value guided goal.

5 mins Homework summary on powerpoint and in workbook

Mindfulness practice at school NotesMindfulness of music – alternative songs provided Give copy of script to facilitator

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Session ObjectivesSession 4:Dropping the struggle

What to do with unwanted emotion?Drop the struggle / Illusion of control / Acceptance

Activity ACT Principle Duration ResourcesMindfulness of Emotion exercise - Externalising an emotion.

Debrief – What did your emotion look like? Where you able to see it as separate from you? Did it seem easier to manage when it was separate from you?

Present moment

Defusion

10 mins Mindfulness script

Recap on previous weekReview homework

Value guided goal Mindfulness of music / Staying with a difficult experience Defusion

What were the difficulties? Were barriers internal or external? What would a wise warrior do?

10 mins

Illusion of control: Control works well in our external world, not so well in our internal world. We would like to have control over our thoughts and feelings, but we don’t really have this! They will come and go whether we like it or not.

Exercise: “Fall in love with that spot on the floor.” Participants talked through an exercise where they are encouraged to fall in love with a spot on the floor. Learning point – you can’t make yourself fall in love with that spot on the floor, just like you can’t make yourself not feel angry.

Rather than trying to control thoughts and feelings/struggle with them. Learn to accept them, and be a wise warrior.

Acceptance

Dropping the struggle

10 mins Script for falling in love with spot on floor

What we can control is our actions - what we do with our mouths, hands and feet. Acceptance / Willingness

10 mins Donuts

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Exercise: There will be times in the future that the urge to act on your anger will be strong, the tiger will be giving you a bumpy journey and you’ll want to put it in its place – can you continue to walk with it? Complete exercise - Urge surfing of sugary donuts and not licking lips. Choice point – choose to let your mind tell you what to do, or walk with the tiger. Encourage young people to use defusion exercises from last week to help them.

Urge surfing script

Complete Valued Living Questionnaire (VLQ) 5 mins VLQs

HomeworkFirst: Say one thing you have learned today?

Value guided goal

5 mins Workbook

Mindfulness practice at school NotesLeaves on a stream Give copy of script to session facilitator

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Session ObjectivesSession 5:Becoming a Wise Warrior for Good

(2 hours in duration to allow questionnaires and focus group)

Review of everythingCommitment plan for futureComplete questionnaires and focus groups

Activity ACT Principle

Duration Resources

Mindfulness exercise – dropping an anchorDebrief – if you are in mindful, wise mode, rather than mindless mode, you can always pause, take a minute and choose how to respond. Dropping an anchor in the present can help.

Present moment

10 mins Mindfulness script

Recap of previous sessionReview homework - Value guided goal : What were the difficulties? Were barriers internal or external? What would a wise warrior do?

10 mins

Recap of what we covered over all sessionsRevisit Zombie summary fighting the tiger and compare to wise warrior walking alongside the tigerEncourage group to reflect on the differencesThe easy option is the zombie – doesn’t require a brain! But doesn’t get you where you want to be either!

Psychological flexibility

20 mins Powerpoint with zombie and warrior and examples of session exercises

Willingness action plan: Begin to complete in class and share – young people to continue to complete at homeGive out certificates

Values and Committed action

15 mins Workbook

Certificates

Questionnaires (SDQ x 2, VLQ, AARS, MAAS-A), mirror tracing task 30 mins Copies of questionnaires

Focus group 30 mins Focus group scheduleDictaphones x 2Memory sticks

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Appendix 7 - Histograms Examining the Distribution of DataPenalty Points

Reward Points

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Total Absences

Absences - Authorised

159

Absences - Unauthorised

Absences - Exclusions

(nb. No histogram for pre as all zero)

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Punctuality – Number of Lates

T-SDQ – Total Difficulties

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T-SDQ – Emotional Problems Subscale

T-SDQ – Conduct Problems Subscale

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T-SDQ – Hyperactivity Problems Subscale

T-SDQ – Peer Problems Subscale

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T-SDQ – Pro-Social Subscale

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Appendix 8 - Raw Scores of Reliable and Clinically Significant Change for Adolescent

Participants

Emotional problems Conduct problems Hyperactivity Problems

PtPostCh RC post CSC

FUCh RC FU CSC

PostCh RC post CSC

FUCh

RC FU CSC

PostCh RC post CSC

FUCh RC FU CSC

Pt 1 1 *n/c - 2 *n/c - 2 Imp yes 2 Imp yes 1 *n/c - 1 *n/c -

Pt 2 2 *n/c - 1 *n/c - -2 Det - -1 n/c - -1 n/c - 3 Imp yes

Pt 3 0 *n/c - -2 *n/c - -2 Det - -2 Det - 2 Imp yes -1 *n/c -

Pt 4 -1 *n/c - 0 *n/c - 2 Imp no 0 n/c - -1 n/c - -2 Det -

Pt 5 3 n/c - 5 Imp yes 1 n/c - 1 n/c - 3 Imp yes 3 Imp yes

Pt 6 0 *n/c - 0 *n/c - -3 Det - -5 Det - -1 *n/c - -4 Det -

Pt 7 2 n/c - 3 n/c - 1 n/c - 1 n/c - 2 Imp yes 0 n/c -

Pt 8 0 *n/c - 2 *n/c - 0 *n/c - 1 *n/c - 2 Imp yes 2 Imp yes

Pt 9 5 Imp yes 0 n/c - 0 *n/c - 1 *n/c - -1 *n/c - -3 Det -

Pt 10 -2 *n/c - 0 *n/c - 0 n/c - 1 n/c - 2 Imp yes 0 n/c -

Pt 11 1 *n/c - 1 *n/c - 1 n/c - 0 n/c - -1 *n/c - 0 *n/c -

Pt 12 1 n/c - 1 n/c - -2 Det - -5 Det - 0 n/c - 0 n/c -

Pt 13 -1 *n/c - 2 *n/c - 0 *n/c - 0 *n/c - 0 n/c - 4 Imp yes

Pt 14 0 *n/c - 1 *n/c - 1 *n/c - 0 *n/c - 0 n/c - 2 Imp yes

Pt 15 3 *n/c - 2 *n/c - 1 n/c - 1 n/c - 3 Imp yes 3 Imp yes

notes: Post Ch= Pre-Post Change; FU Ch= Pre-Follow up Change; FU= Follow Up RC= Reliable Change; CSC= Clincally Significant Change

Peer problems Pro-social Total Difficulties

PtPostCh RC post CSC

FUCh

RC FU CSC

PostCh RC post CSC

FUCh RC FU CSC

Post

Ch RC post CSCFUCh RC FU CSC

Pt 1 -2 *n/c - -2 *n/c - 4 Imp yes 4 Imp yes 2 *n/c - 3 *n/c -

Pt 2 -3 Det - 0 *n/c - -1 n/c - -1 n/c - -4 n/c - 3 n/c -

Pt 3 -2 *n/c - 0 *n/c - 0 n/c - -1 n/c - -2 *n/c - -5 Det -

Pt 4 0 *n/c - 0 *n/c - 0 n/c - 0 n/c - 0 n/c - -2 n/c -

Pt 5 -1 *n/c - -1 *n/c - 1 *n/c - -1 *n/c - 6 Imp yes 8 Imp yes

Pt 6 -1 *n/c - -1 *n/c - -3 n/c - -2 *n/c - -5 Det - -10 Det -

Pt 7 1 n/c - 1 n/c - 4 Imp yes 1 n/c - 6 Imp - 5 Imp -

Pt 8 0 *n/c - 0 n/c - 3 n/c - 1 *n/c - 2 n/c - 5 Imp yes

Pt 9 5 Imp yes 3 Imp yes 1 n/c - -1 n/c - 9 Imp yes 1 n/c -

Pt 10

2 n/c - 1 n/c - -1 n/c - -1 n/c - 2 n/c - 2 n/c -

Pt 11

-1 *n/c - 0 *n/c - -1 *n/c - -3 n/c - 0 *n/c - 1 *n/c -

Pt 12

0 *n/c - -2 *n/c - -1 n/c - -3 n/c - -1 n/c - -6 Det -

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Pt 13 1 *n/c - 1 n/c - -2 *n/c - -1 n/c - 0 n/c - 7 Imp yes

Pt 14 0 *n/c - 1 n/c - 5 Imp yes 0 n/c - 1 n/c - 4 n/c -

Pt 15 1 n/c - 1 n/c - 0 n/c - 0 n/c - 8 Imp yes 7 Imp -

notes: Post Ch= Pre-Post Change; FU Ch= Pre-Follow up Change; FU= Follow Up RC= Reliable Change; CSC= Clincally Significant Change

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Appendix 9 – Example extracted codes from effectiveness interviews

Interview Timepoint

Partic-ipant Extract from transcript Codes

Potential theme / subtheme

post 9 .. and have you noticed any change, then so when he does get called in to account or pulled up to account for his behaviour?

Little bit more um, yeah a little bit more reflective, and won’t necessarily be as, as an negative towards the member of staff. he’ll take his punishment, from what I’ve seen, yeah he will just be, will think about his actions before he actually says anything.

more reflectiveless negative interactionaccepts punishment

reflective

ownership

FU 3 Umm, he does still get into trouble, he can at times think about what he’s doing before he speaks or before he acts, but he um, it comes and goes with him.

reflectivefluctuates

reflective

post 11 <when talking about adolescent participant who has overcome the problem, and thinks about how he is perceived>...Um, because there’s an issue that we have in this School, they, they present themselves in a manner that they don’t necessarily think is wrong, so kissing their teeth, to them might not be an issue, but it’s the equivalent of swearing to somebody, but they don’t always connect that, um rolling the eyes, walking around like with a, real screw face. They don’t necessarily know that they’re doing it, and so the teacher is reading that information and seeing it is negative, and when confronted about it the kids sometimes get defensive because they don’t necessarily know what it is that they’re doing so then they feel like they’re being picked on and then you have this endless carousel and if you’ve got new members of staff, who don’t know the students yet, they are going to follow the procedures in the sense that, ‘well you didn’t do this, so it’s a C Point’ before they actually talk to the student about it, so then they can become quite frustrated.

unaware non-verbal communication

student-teacher mis/perceptions

perpetuate problems/reciprocal nature of interactions

perceptions and reciprocity

post 15 so he feels, he’s always been a part of his year group, but now I think he really feels a part and he doesn’t feel he has to be naughty to be a part. So he’s made a lot of progress and I’m really happy.

group gave sense of belongingknock on effect for behaviour

perception of group

FU 11 So um, there has been an improvement in terms of his interactions with staff and his willingness to do succeed, but it’s questionable in terms of his, his temper with students when pushed. So if someone keeps annoying him he doesn’t necessarily know how to control that.

improved interactions with staffanger problems with peers continue

reflective

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Interview Timepoint

Partic-ipant Extract from transcript Codes

Potential theme / subtheme

FU 7 Um In terms of giving him a group as an intervention, I think he finds it very hard to accept that he needs any type of intervention and I think unfortunately for him, I think where this group, I think if it had been a group where he had been a part of for a longer space of time, it may have had a bigger impact because I think it takes him a while to actually accept, okay I do need this support. So I think maybe in hindsight the length of this program may have been too short for him.

sense of belonging to the group

need longer duration (feasibility)

perception of group

Post 9 Um, he has some SEN need and we are in the process of putting an education plan for him just to find out what support he actually needs from us, and how we can help him further, but there has been a definite, definite improvement in him.

SEN needs EHCPadditional teacher support

Beyond the group

FU 2 I think maybe he’s a little bit more willing to change and open to feedback he, he loves positive praise and he absolutely hates getting into trouble as any child does, but some have a thicker skin, and for him it resonates a little bit more. So I think, y’ he’s probably just had enough of being the naughty one and being, he just wants to just get on with his work, and be recognised for positive stuff, and that’s definitely, definitely happening

wanting praise from teachersrecognition for positives not problem behaviourperception

reciprocal relationshipperceptions

FU 5 Also at the same time as this ‘ meeting I have met with mum who was very supportive, um, he’s got a beautiful relationship with his mum so he has realised that, yes the school recognised that there was a concern and his friendship groups; and so another thing that came out from meeting with mum was that he didn’t have a lot of social time with his friends, which he was yearning for and mums worked with him on that so I think that’s made him feel a bit more part of the team so when via talking about events they did at the weekend he can contribute because he was there so I don’t think he was so anxious. I think mixing with girls he’s a lot more settled and confident about himself which means that he doesn’t feel the need to flareup and he’s continued his counselling so he’s doing well academically he is done well his health and well-being has never really been a concern for us, um and he’s had no situations with teachers or with his peers.

input from parentwider perspective of other factor affecting boysocial difficultiesseeing counsellor

Beyond the group / Multiple influences

12 I think it’s been a consistent progression from the beginning of the yearpost 3 so if I just focus on him in business, otherwise I don’t see him I just see him in corridors and in

terms of assemblies and things. Um yeah he will, so he won’t just react, he will think about it and he will, he will respond in a calmer manner but he will still continue with what ever is that he’s doing. so in that sense yes, but he’s, but no <laughter>

think / reflect before actingchoose less desirable behaviour

reflective

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Interview Timepoint

Partic-ipant Extract from transcript Codes

Potential theme / subtheme

post 8 Um, since he’s been on the group he’s, he just doesn’t seem to, I mean well there was an incident after school, which he got involved with the other day it was to do with <name of relative>, but he um did react but he will tell you well with <name of relative>did that and that, but I just did this, so he’s still very honest,

honest / owns upcommunicates with teacher

Takes Ownershipreciprocal relationship

post 10 yeah so it fluctuates, for him it’s up-and-down and to be honest he struggles more in a double lesson he finds that very difficult and gets bored very quickly, I mean two hours of siting down focusing is hard for anybody but he will start to act up when he’s bored

flutcutatesstruggles in double lesson

beyond the group / other factors

FU 4 And do you think that the change in his behaviour is because of that more responsibility?Yeah it yeah, because we’re trusting, we’re seeing that he is, he is trying so then the trust is developing and we know that he’ll do a good job, as opposed to take the mick and throw the paper away or whatever it is that we’re asking him to do, so yeah he has he has definitely improved in that sense

trust developing between staff and student

Reciprocal nature of student - teacher relationship

post 2 he will sit and reflect and before he opens his mouth, he didn’t have an off switch, and he wouldn’t be able to control his, whatever it is, that he was doing it would just come out and he’d become very anxious and very frustrated if he wouldn’t get his way. He has calmed down an awful lot, he’s still not perfect, um but, he’s definitely trying and you can definitely see a change in him.

trying / motivatedprevious frustration, now calmer

reflective

FU 6 That <name of boy> has started to think about what he’s doing and he, he’s trying to take a step back and look at, okay I did this, what’s the best way of dealing with the situation instead of just letting all out verbally, and then dealing with the consequences afterwards?

more reflective , thinking before acting

reflectiveownership

Post 2 His interactions with teachers he again like I said before he, hes thinking before he reacts which is having impact. And that equates through his lack of G, C points so there is, yeah I’ve definitely seen an improvement in him

added benefits of improved relationship with teachers more reflective , thinking before acting

reflectivepositive reciprocal relationship

FU 13 He has calmed himself down, a lot, but he’s still got a bit about a bit of the journey to go on. longer term perspective of change

Beyond the group / longer term progression

Post 15 He has calmed down an awful lot, he’s still not perfect, um but, he’s definitely trying and you can definitely see a change in him.…made so much progress since year eight...

behavioural improvementlonger term perspective of improvement

Beyond the group

Appendix 10 – Example extracted codes from feasibility interviews

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Interviewtime-point

Teac-her Extract from transcript Code

Potential theme / subtheme

post 5 I think the group is very beneficial. I think it’s nice that students get an outside opinion, I think sometimes in the school you just hear the same things, but they’re teachers, um so I do think it’s really beneficial

positive view of group

external person helpful to bring new ideas / outside opinion

facilitator

post 1 could you run it without us? Could you envisage it as something that schools generally could run themselves?What teachers? Potentially, well however you think it could runNo, no, I think it would have to be someone with a therapeutic background or, otherwise it would not workOK So support staff or someone specifically..?Teachers teach, I don’t know they, you guys facilitated this group, I think there’s quite a big difference.

therapeutic background of facilitator

teacher vs therapist facilitator

facilitator

post 5 I think it’s nice for the students to work with someone they don’t see every day which means they can go, learn and come away and not feel like whatever they may open up at the meeting, or what have you isn’t a constant reminder for them,

external facilitator

opening up to outside person better

facilitator

Pre 4 particularly if they see the purpose and the need for it. It’s difficult to say really at this stage as to how they will commit to it, just cause you don’t want it to be enforced as such, it needs to be something that they will benefit from

engaging the boys, to see the benefits

avoid enforced involvement

engagement

pre 3 and I think that if it’s done in a way of how it’s anger, because automatically they’re going to be stigmatised that they have a problem and I think that, it’s, that’s something to look at, as to how it’s branded with the student.With most students nobody likes to be highlighted, or to made public that they have an issue, ‘cause they’re young people and I think that for them it’s a big thing, it’s their whole bravado, it’s their public image so automatically they might be a little bit hesitant in terms of opening up and engaging in the process because it already has a negative connotation attached to it.

need to minimise stigma

how sell to/engage boys

engagement whilst monitoring stigma

Interviewtime-point

Teac-her Extract from transcript Code

Potential theme / subtheme

Pre 4 so I guess fitting that mindfulness in might be, might be difficult but ensuring there’s at time that the children are committed to it and <school co-facilitator> is able to, to do it, then it will work.

logistics of fitting in mindfulness

need commitment from staff and students

logistics

pre 3 the systems will have to be tight. Because obviously we are quite rigorous and robust in terms of implementing things and rolling it out into school that we don’t want students to use it as an opportunity to be walking out of class so the system that you put in place is very important that it is tight and everybody, it is shared and everybody knows what it’s about, students know their times there’s minimal room for slippage, for students to be I guess skylarkin’s the best word, or dilly dallying too and fro.

challenges envisaged – needing to know where students are, not wandering

sharing information

embed into school systems

embedding

logistics

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THE PART 3 – SUMMARY OF CLINICAL EXPERIENCE

Year 1 - Working Age Adult Split Placement

I was based in a secondary care Community Mental Health Team (CMHT) and a primary

care adult Improving Access to Psychological Therapies (IAPT) service. I also contributed

to a brief systemic family therapy clinic on an acute psychiatric inpatient ward. Across

these services, I worked with working aged adults with a range of psychosocial

adjustment difficulties and mental health difficulties including, depression, anxiety

disorders, eating disorder, psychosis and bipolar affective disorder. I completed

psychological, neuropsychological and risk assessments with adults from diverse cultural,

socioeconomic backgrounds and age groups. I provided psychological formulation and

interventions using cognitive behavioural therapy (CBT) and systemic family therapy both

as a co therapist and part of a reflecting team. I co-faciliated a 10 week CBT group for

adults with a diagnosis of bipolar affective disorder, and completed a service evaluation

project examining the group.

Year 2 - Adult Community Learning Disabilities Placement

Within a community learning disability team, I supported adults with a mild to severe

learning disability, often occurring with additional co-morbid difficulties including autistic

spectrum disorder (ASD), behaviours that challenge, sensory difficulties, chromosome

disorders, mental and physical health difficulties. I conducted dementia assessments,

autistic spectrum disorder (ASD) assessments, assessment of a client’s sexual knowledge,

functional and cognitive assessments as part of an assessment for the presence of a

learning disability. I delivered psychological interventions using adapted CBT. I also used

positive behaviour support to develop support plans for families, carers and care staff to

support adults presenting with behaviours that challenge.

Year 2 - Children and Families Split Placement

This placement was split between a tier 2 youth offending team (YOT) and tier 3 child and

adolescent mental health service (CAMHS). I completed clinical assessment and

formulation of children and adolescents (age 4-18 years) with a range of presentations

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including depression, anxiety disorders, Autism Spectrum Disorder (ASD), behaviour that

challenges, anger and aggression difficulties. In the YOT I worked with young people with

additional complicating socioeconomic factors such as social deprivation, gang affiliation,

housing problems, alcohol and substance abuse, parental mental and physical health

difficulties. I delivered individual psychological interventions, both directly and indirectly

through parents using cognitive behavioural therapy, systemic and behavioural

approaches, adapting the content to suit developmental stage. I designed and co-

facilitated a social and emotional wellbeing group for adolescents at the YOT. I offered a

psychological understanding through contributions to team around the child (TAC)

meetings and education, health and care plans (EHCP).

Year 3 - Older Adult Split Placement

During this 6 month split placement I worked with older adults aged 63-92 years, across

three services; an older adults CMHT, a memory assessment service (MAS), and a

behaviour and communication support service (BACSS). Within the MAS I developed skills

in the neuropsychological assessment of dementia. In the CMHT I delivered psychological

interventions using systemic therapy approaches, including narrative therapy to support

older adults with a range psychological difficulties such as depression, anxiety and

adjustment difficulties. In BACSS I used the Newcastle Model to develop care plans for

staff in residential care homes supporting older adults with a diagnosis of dementia that

were exhibiting behaviours that challenge. I enhanced my knowledge and skills of

capacity, deprivation of liberty and risk assessment throughout this placement.

Year 3 - Specialist Children Looked After Placement

This CAMHS service based within the local authority offered me the new opportunity to

work, directly and indirectly through carers and other professionals, supporting children

looked after (CLA) age 0-18 years. Young people presented with a range of emotional and

behavioural difficulties including, trauma, difficulties establishing and maintaining

attachment security, inappropriate sexualised behaviour, anger difficulties, low mood,

anxiety, behaviours that challenge, deliberate self-harm, school engagement difficulties

and emerging emotionally unstable personality disorder. Some young people had

neurodevelopmental difficulties including learning disability and ASD. I offered weekly,

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individualised consultation to social workers, foster carers and the wider professional

network supporting children looked after. I delivered integrated psychological

interventions informed by CBT, narrative therapy, dyadic developmental psychotherapy,

mindfulness, dialectical behavioural therapy (DBT), attachment theory and systemic

theory. I developed skills in risk management particularly around child sexual exploitation

and working systemically within the wider network to support children in care. I

enhanced my understanding of safeguarding and child protection procedures.

Across all placements I contributed to multi-disciplinary team meetings and case

formulation, assessed and managed risk, completed formal observations, wrote letters

and reports to clients and professionals; adapting the content to the audience. I delivered

training and presentations on a range of topics to a variety of client and professional

groups. Neuropsychological assessments, feedback and reports were undertaken across

all placements; assessments included, WASI-IV, WISC-IV, WYATT, WMS-IV, TOPF-UK,

NEPSY, RBANS, MOCA, Hopkins Verbal Learning Test, Verbal and Semantic Fluency Test,

Trail-Making Task, Rey Complex Figure Task, Hayling and Brixton Tests.

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PART 4 – TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

PSYCHD CLINICAL PROGAMME

TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Year I Assessments

ASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity

Assessment and formulation of a male in his mid-40’s experiencing symptoms of depression.

Audio Recording of Clinical Activity with Critical Appraisal

Audio recording and critical appraisal of the 5th session of cognitive behavioural therapy with “Ella”; a young woman in her early twenties experiencing anxiety and beliefs that eating meals away from home will lead to bowel disturbance.

Report of Clinical Activity N=1

An N=1 report of a young woman in her early twenties with anxious beliefs that eating meals away from home will lead to bowel disturbance.

Major Research Project Literature Survey

Parent and family involvement in interventions targeting anger and aggression in adolescent males.

Major Research Project Proposal

Research proposal for a feasibility study into the acceptability of a school based act intervention for anger in adolescent males: a teacher and school perspective.

Service-Related Project Factors involved in retention to the ‘Mood on Track’ Group; a cognitive behavioural therapy psycho-educational group for bipolar affective disorder delivered by secondary care community mental health team.

Year II AssessmentsASSESSMENT TITLE

Report of Clinical Activity – Formal Assessment

A diagnostic assessment of a learning disability in a young adult male presenting with anxiety and a diagnosis of autism spectrum disorder.

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PPLD Process Account A reflective account of the experience of a personal and professional learning discussion group for trainee clinical psychologists.

Year III Assessments ASSESSMENT TITLE

Presentation of Clinical Activity

Presentation of the psychological assessment and intervention with “Young MZ” in a youth offending team setting.

Major Research Project Literature Review

Acceptance and Commitment Therapy for Adolescent Mental Health: A Systematic Review.

Major Research Project Empirical Paper

‘Taking ACTion On Anger’: A school perspective of the feasibility and preliminary efficacy of a brief ACT intervention for anger in adolescent males.

Report of Clinical Activity

A systemically-informed assessment, formulation and intervention in a care home context, with a nun who is experiencing low mood, physical health and relationship difficulties with care home staff.

Final Reflective Account On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training.

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