Taking ACTion on Anger: A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males in a school-

context.

Jennifer Livings

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, SurreyUnited 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or unpublished) are fully identified as such within the work and attributed to their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: Jennifer Livings

2

Overview

This e-thesis summarises the four key components that have contributed to

the degree of Doctor of Psychology (Clinical Psychology). Parts 1 and 2 detail the

research projects undertaken during the course of study. Specifically, part 1 is a

systematic literature review investigating the status of psychologically-based

interventions for adolescent males with difficulties with anger and aggression. The

literature review highlighted a lack of diversity of interventions in the field, a lack of

interventions targeted specifically at males, a lack of UK-based studies, and a variety

of methodological issues with several studies.

Part 2 presents a feasibility study attempting to address some of the

limitations identified in the literature review. A short-term Acceptance and

Commitment Therapy-based intervention was designed, delivered and evaluated in a

school setting in London, UK. The intervention was designed specifically for

adolescent males, and was evaluated using quantitative (questionnaire) and

qualitative (focus group) outcome measures. The results indicate that the intervention

is acceptable to the participants and feasible (with some adjustments) to run in a

school setting. The questionnaire measures were, on the whole, unacceptable. In

regard to changes, quantitative outcomes were largely non-significant; several

explanations for this are proposed. Qualitative data suggested that the participants

experienced numerous positive changes following attending the group.

Part 3 presents a summary of the clinical experiences gained over the course

of training in the 5 clinical placements undertaken in different settings. Finally, Part

4 is a summary of the academic assignments successfully completed and passed

during the course of training.

3

Publications

Parts of this thesis have been presented at the following conference:

Livings*, J., Parker*, H., & 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.

4

Table of Contents Page

Number

Acknowledgements 6

Research Part 1 – Literature Review 8

Research Part 2 – Empirical Paper 82

Appendices 145

Part 3 – Summary of Clinical Experience 251

Part 4 - Table of Assessments Completed During Training 254

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Acknowledgements

I would like to extend my gratitude to my friends, family, colleagues, and

supervisors, who have all helped me to successfully complete a demanding three-

year training course. Firstly, I would like to thank Mary John for being a strong,

professional role model, both as course director and my research supervisor, and for

always making time to support me, despite your demanding schedule. The course

team as whole have provided me with the knowledge, skills and confidence to

progress in my career as a clinical psychologist, and I would particularly like to

thank Melanie Smart, Nan Holmes, Kate Gleeson, and Laura Simonds for their

contributions to the training. Furthermore, my clinical supervisors on placements

have helped me to develop my skills and confidence in the “real-world” of the NHS,

and their optimism, encouragement, and faith in my abilities has engendered

confidence in me.

To my peers in Cohort 43; we have got through this together! I’m so grateful

to have been part of such a supportive, non-judgemental, and skilled group of people,

that have encouraged each other’s development, rather than competed against one

another – you are all amazing! Particular mention is needed for the members of

“Team Organic”; you have been a rock of support through the emotionally

demanding times on the course, and you have inspired me with your knowledge,

resilience, optimism, and determination.

To my friends and family, thank you for believing in me, understanding when

I have been unavailable as I have been buried under assignments, and provided me

with much needed fun and downtime outside the course.

6

Finally, and most importantly, to Spencer. Thank you for putting up with me,

supporting me in every way possible, allowing me to be unreasonable, reminding me

that things will always be alright in the end, and making me smile in the tough times.

7

Research Part 1 – Literature Review

Title: Psychological interventions for anger and aggression in adolescent males: A

systematic review of 21st Century interventions

Word Count: 7993 (excludes abstract, figures, tables, and references)

8

Abstract

Mental health problems are becoming increasingly prevalent in children and

young people. For adolescent boys, conduct problems are a common manifestation of

this. This review considers psychological interventions for adolescent boys

struggling with anger, aggression and conduct problems. A systematic search of the

literature published since 2000 resulted in 19 articles, pertaining to 18 studies. A

recent time-frame was selected to ensure the interventions under review were

relevant to the current cohort of adolescents. It was found that, similarly to the more

historical research, much of the recent research is limited to interventions based upon

a social skills/CBT framework, highlighting a lack of breadth of intervention options.

In addition, many of the studies suffered from methodological difficulties. Over 50

different outcomes were considered across the studies; examples include self-report

measures of anger, teacher reports of behavioural problems, and measures of self-

esteem. Outcomes for the adolescents were, on the whole, mixed, with some authors

finding large effect sizes (e.g. Down, Willner, Watts, & Griffiths, 2011, d=1.07-

1.58), but many others finding much smaller effect sizes (e.g. Herrmann &

McWhirter, 2003, d=0.10-0.13), and/or non-significant results (e.g. Puskar, Grabiak,

Bernardo, & Ren, 2009). Suggestions for future research are provided including

developing interventions that are keeping up with modern youth, targeting

interventions at specific subgroups of adolescents (e.g. those who are at risk), and

developing a broader range of therapeutic approaches for this client group.

Key words: adolescent, anger, aggression, intervention, boy

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Introduction

Globally, up to 20% of children and adolescents are reported to suffer from a

“disabling mental illness” (see World Health Organisation, 2003). A 2015 survey of

48 Child and Adolescent Mental Health Services (CAMHS) in the UK showed that

276,468 children and young people were referred to them in that year (Children’s

Commissioner for England [CCE], 2016). Of these, the vast majority were over 11

years of age, and 41% were male (CCE, 2016). Whilst recent data is lacking, the

Office for National Statistics (2005) survey in Great Britain found prevalence rates

for children and young people experiencing a mental health problem to be as high as

1 in 10. Amongst adolescents (11-16 years old), boys were reported to have

experienced more mental health problems than girls (12.6% v 10.3%). The most

common mental health difficulty experienced by adolescent boys was conduct

disorder, with a reported prevalence rate of 8.1%. The figures suggest that a

significant proportion of adolescent boys struggle with their emotional wellbeing,

and specifically with conduct disorder. Conduct disorder is a persistent pattern of

behaviour that violates societal norms or the rights of others, and will include some

of the following: aggression to people or animals, destruction of property,

deceitfulness or theft, and serious violations of rules (American Psychiatric

Association, 2013). Given the estimated economic impact of conduct problems has

been suggested to be in the region of £260,000 per child (Parsonage, Khan &

Saunders, 2014), establishing the current status of effective interventions is important

at both an individual and societal level. The focus of this review was to establish

what psychological interventions currently exist to support adolescent boys with one

of the common markers of conduct and related difficulties; specifically, what

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interventions are available to support adolescent males with anger and aggression

difficulties.

An historical overview of the existing literature revealed several key areas for

development. Firstly, it became apparent that anger management interventions were

a significant area of research during the 1980s and 90s, but appeared to have declined

since. Much of this early research is based on a cognitive-behavioural therapy (CBT)

framework (see Lochman, Powell, Boxmeyer, & Jimenez-Camargo [2011] for a

description of typical components of CBT for conduct disorder in children and

adolescents). For example, Deffenbacher, Lynch, Oetting and Kemper (1996)

demonstrated that both social skills training and cognitive-relaxation coping skills

programmes were effective in reducing anger and aggression in 11-14 year olds.

Feindler, Ecton, Kingley and Dubon (1986) showed that their cognitive-behavioural

based “anger control” programme was effective at reducing aggressive acting out

behaviours in adolescent psychiatric patients. In their meta-analysis of 50 studies of

CBT for adults, adolescents, and children (n=1640), Beck and Fernandez (1998)

found a weighted mean effect size of 0.7 for CBT over controls.

Research in the 2000s appeared to be less common. Sukhodolsky, Kassinove

and Gorman published their meta-analysis in 2004 of CBT treatments for anger in

children and adolescents (total n=1953; mean percentage of males per comparison =

82%). The studies included were published between 1974 and 1997, resulting in

notable overlap (13 studies) with the Beck and Fernandez (1998) study. The authors

found beneficial effects of CBT for anger (d=0.67), and whilst age was not found to

be a significant moderator of outcome, a trend for more beneficial outcomes in older

children (15-17 years, d=0.74) as opposed to younger children (7-10 years, d=0.54),

was observed. In addition, interventions that were more behavioural in their focus

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were more effective. In one of the most recent meta-analyses, Fossum, Handegard,

Adolfsen, Vis, and Wynn (2016) evaluated the long-term treatment effect of

outpatient interventions for children and adolescents with conduct problems. 2,821

participants across 56 studies were included. 37 of these had been published since

2000, but only four of these focused on an adolescent-only population. The authors

concluded that there is an improvement in conduct problems pre- to post- treatment

(overall mean weighted effect size for between groups = 0.64), which was retained at

follow-up.

The lack of recent research into adolescent anger difficulties is important to

consider in relation to cohort effects. Today’s teenagers witness the presence of

global terrorism (Call et al., 2002), engendering a continued threat of violence.

Increased immigration has created a different sociocultural environment to that of

older generations, with the consequence being the potential for intergenerational (see

Call et al., 2002) and intergroup conflict (Larson, 2002). Perhaps the most notable

change is the increased availability of the internet, and particularly social media.

According to a recent survey of American teenagers (Pew Research Center, 2015),

92% go online every day, and 71% access more than one social media site. Whilst

social media has many potential benefits to young people (O’Keeffe, Clarke-Pearson,

& Council on Communications and Media, 2011), increased internet usage has been

associated with increased depression and loneliness (Kraut et al., 1998), and

cyberbullying has a notable presence (Smith et al., 2008). The unique experiences of

“Generation Z” (see Strauss & Howe, 1991) and beyond require consideration in the

continued evaluation, development and innovation of interventions, in order to

maintain cohort-relevance.

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A second observation from the existing literature is that the primary

theoretical approach researched is CBT. Blake and Hamrin (2007) reviewed the

literature on interventions for 4-18 year olds and found that CBT-based programmes

predominated, although they varied in their specific components (e.g. social skills

training, versus studies modifying attribution biases, etc). More recently, of the 56

studies in Fossum et al.’s (2016) meta-analysis, 52 of these were either behavioural

therapy, CBT, or a combination of these. One specific CBT-based intervention

appears to have been particularly well-researched. Aggression Replacement Training

(ART) has three main components; social skills training, anger control training, and

moral reasoning (see Fonagy et al. [2005] and Reddy and Goldstein [2001]). The

programme was originally implemented with high risk, institutionalised adolescents

(Glick & Goldestein, 1987) with results supporting its effectiveness. More recent

research has shown its effectiveness with children and adolescents recruited from

school settings (Gundersen & Svartdal, 2006).

Whilst there is a clear trend in the literature towards CBT-based

interventions, Multisystemic Therapy (MST) is one of the few notable alternatives

offered. MST is rooted in social-ecological and family systems theory, positing that

antisocial behaviour is multi-determined, including influences such as school, work,

family, culture, and others, as causal factors (Henggeler, 1999). MST emphasises

strengths within the system, and intervenes where sequences of behaviour are

maintaining difficulties (Henggeler, 1999). The current NICE (2013) guidelines for

children and young people with antisocial behaviour and conduct problems

recommend MST as one intervention for young people aged 11-17. Weiss et al.

(2013) found that compared to controls, parents and young people who were in

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receipt of MST reported “significantly greater rates of decrease in externalizing

problems” (d ranging from 0.25-0.43).

Whilst MST offers an alternative to the CBT model, it is highly resource

intensive, with a full-time therapist being available to see a family 24/7 (Fonagy,

Target, Cottrell, Phillips, & Kurtz, 2005). Although initial research demonstrates

some evidence for MST’s cost effectiveness (Cary, Butler, Baruch, Hickey, &

Byford, 2013), the start-up resources required could be a significant barrier to

enabling widespread access to it.

A third observation from the existing literature is that a sizeable proportion of

the research has focused on younger children and pre-adolescents (e.g. Kazdin,

Siegel, & Bass, 1992; Lochman, Burch, Curry, & Lampron, 1984; Sukhodolsky,

Golub, Stone, & Orban, 2005; van Manen, Prins, & Emmelkamp; 2004). Wilson,

Lipsey and Derzon (2003) carried out a meta-analysis of school-based interventions

for aggression, however only 21% of included studies contained populations aged 14

+. Similarly, in Fossum, Handegard, Martinussen and Morch’s (2008) meta-analysis,

only 12-13 of the 65 included studies had a mean age greater than 13, whilst Fossum

et al.’s (2016) meta-analysis contained only four studies with a mean age greater than

13. Furthermore, the research that has occurred with adolescents has produced mixed

findings. Wilson et al. (2003) reported that interventions tended to be more effective

for the youngest (under 5; effect size=0.33) and oldest (14 +; effect size=0.37)

participants, and more effective for higher risk young people (effect size=0.41 v 0.09

for general population). Similarly, Sukhodolsky et al. (2004) reported a trend for

greater benefits in older children. In contrast, Fossum et al. (2008) found effect sizes

with adolescents tended to be smaller than those with children (moderator

variable=mean age, d=-0.54).

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The aim of this systematic literature review was to build on the earlier

summary work to establish what research has occurred since the initial anger

management research of the 1980s and 90s. The review considers papers published

since 2000, with a focus on establishing what works for adolescent males with anger-

related difficulties. The review adds to previous research by a) broadening the scope

of the interventions included beyond CBT; b) focusing on adolescents only (age

13+); and c) focusing the search on males, given their higher prevalence of conduct

disorders. In addition, in the current context of global economic difficulties, the

review was seeking to establish the effectiveness of interventions that are feasible to

implement in regard to time and resources.

Method

The initial search terms and databases were generated through inspection of

the terms used by similar articles, and discussion with the principal supervisor and

research team. Final search terms and databases can be found in table 1.

Table 1

Search terms and databases

Generic term Specific search terms used Databases

Adolescent male

youth* OR juvenile* OR teen* OR young* OR adolescen* OR boy* OR pupil* (all in Abstract)

EBSCO search of:PsycINFOPsychology and Behavioural Sciences CollectionChild Development and Adolescent StudiesPsycARTICLESMEDLINE

Cochrane Collaboration search of:Cochrane reviewsCochrane trials

Anger or aggression

anger OR aggress* OR conduct (all in Abstract)NB: “conduct disorder” rather than “conduct” was used in the Cochrane search as the term “conduct” led to too many erroneous results as many studies included the word “conducted”.

Intervention intervention OR program*(all in Abstract)

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The initial EBSCO search was conducted first in January 2015, with the

following limiters applied:

1. Publication date: 2000-2015

2. Scholarly peer-reviewed journals

3. English language

This produced 4670 results and thus an additional limiter was applied to focus the

search on the relevant population:

4. Adolescence (13-17 years)

This produced 1517 results that proceeded to the initial abstract screening.

Consideration was given to include the term “therapy” as an addition to

“intervention” OR “program*”. However the inclusion of this into the EBSCO

search increased the results to over 2,700. An abstract screen of the 30 most relevant

articles produced only one potentially additionally relevant result. It was thus

decided that the “intervention” OR “program*” terms provided the optimum balance

of inclusiveness and specificity.

The search was also performed in the Cochrane collaboration database (only

limiter used = publication date; no option present for other limiters). This returned

164 “reviews”, which were combined with the 1517 results to produce 1681 total

results. Five duplicates were removed, resulting in 1676 articles that proceeded to

abstract screening. The Cochrane search also produced 245 “trials”. After duplicates

were removed, 173 additional trials remained for abstract screening.

To focus the search on the most pertinent populations, several further

exclusion criteria were applied, which are summarised in table 2. For example, as the

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desired population was adolescents, studies were only included if the participant

mean age was ≥ 13 years. Interventions that were looking at populations with dual

diagnoses (e.g. substance misuse) were excluded as it was thought that the

“anger/aggression” component may be confounded by other contextual factors. As

the focus of the review was to ascertain interventions available for adolescents

specifically, interventions that were parenting or family focused were excluded1.

Furthermore, as MST is highly resource intensive, it was decided to focus the review

on interventions that may be more financially feasible to implement. MST, and

interventions that were 6 months or longer in duration, were thus also excluded.

Whilst the focus of the review was on males, interventions that included both

genders were included. Mixed-methods papers were retained in the review, however

only the quantitative results are reported. Qualitative papers (and qualitative results

in mixed-methods papers) were excluded for ease of comparison and consistency

purposes, as the majority of studies were evaluated using quantitative measures.

The entire process was repeated in October 2015, and February 2016 to

capture any recent studies. One further relevant study was located (see figure 1 for

screening flow chart and table 2 for full breakdown of inclusion and exclusion

criteria).

1 Studies were however retained if the main intervention focused on the adolescent but it also included an additional parenting component.

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Figure 1. Record selection process

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Additional Searches in October 2015 and February 2016 (repeating above process), yielding n =1)

Final total studies included(n = 19)

Records screened via abstract(n=1849)

Records excluded(n = 1780)

Records after duplicates removed

(n = 1676)

Studies initially included(n = 18)

Records excluded(n= 51)

Records screened via full text(n = 69)

Records after duplicates removed(n = 173)

Table 2

Reasons for exclusion

Category for exclusion Reason for exclusion

Population issues Not on adolescentsOn non-western sampleLearning disability/developmental disability/neurological impairmentsIntervention only focused on girls

Intervention on dual diagnosisInpatient/residential/prison settingMean participant age was less than 13

Intervention issues Intervention clearly not psychologically basedUnrelated to violence/aggressionIntervention focused on dating violence/intimate partner violenceIntervention focused on bullyingPaper focused on parenting/family therapyLength of intervention greater than or equal to 6 monthsResource intensive intervention (e.g. Multi-systemic therapy)

Methodological issues Not in EnglishCase report/qualitative studyNot an intervention studyNot looking at anger/aggression as primary outcome

Other DuplicateStudy unrelated to topic

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Results

The 19 manuscripts selected for inclusion are summarised below, and in

tables 3-6. Two of these (Puskar et al., 2009; Puskar, Ren, & McFadden, 2015)

appear to be referring to the same study2, and will therefore be discussed as one

study.

Quality assessment

The Critical Appraisal Skills Framework (CASP) (2014) was used as a basis

for appraising individual studies, particularly the randomised controlled trial (RCT)

checklist. The CASP frameworks provide criteria by which to appraise studies

against, to assess their methodological rigour and the overall quality of the evidence

provided. It provides a series of questions for the reviewer to consider, with the

answers to said questions giving an indicator of the quality of the evidence. An

example of a question, in the RCT checklist is, “Aside from the experimental

intervention, were the groups treated equally”. The checklists were applied flexibly

to fit the particular studies and have helped guide the critique, but were not adhered

to rigidly given many of the studies were “pre-post” designs, for which there was not

a specific CASP checklist available.

Nature of intervention

11 studies were based around a broadly cognitive behavioural framework

(including social skills training) (Bidgood, Wilkie, & Katchaluba, 2010; Cheng,

Haynie, Brenner, Wright, Chung, & Simons-Morton, 2008; Down et al., 2011;

Hermann & McWhirter, 2003; Humphrey & Brooks, 2006; Langeveld, Gundersen &

Svartdal, 2012; Martsch, 2005; Moynahan & Stromgren, 2005; Puskar et al.,

2 One of the authors was contacted to request confirmation of this, but no response was received. Given the two papers referred to the same intervention, number of participants, and mean age, it was assumed that they referred to the same study.

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2009/2015; Robinson, Smith & Miller, 2002; Williamson, Dierkhising, & Guerra,

2013), and one (Hanselman, 2001) integrated this with an attachment-based

underpinning. Of the remaining six studies, all adopted a different approach,

including mindfulness (Singh et al., 2007), expressive writing (Kliewer et al., 2011),

a skills-based curriculum incorporating a martial art (Farrell et al., 2003), a brief

writing exercise aimed at buttressing self-esteem (Thomaes et al., 2009), an

intervention based on the Theory of Reasoned Action (TRA; Meyer et al., 2004), and

an “incremental theory” intervention targeting aggressive responses to victimisation

(Yeager et al., 2013).

Study design

11 of the studies were RCTs (Cheng et al., 2008; Down et al., 2011; Farrell et

al., 2003; Hermann & McWhirter, 2003; Kliewer et al., 2011; Langeveld et al., 2012;

Martsch, 2005; Puskar et al., 2009/2015; Robinson et al., 2002; Thomaes et al., 2009;

Yeager et al., 2013), three were controlled trials without randomisation (or failed to

mention if randomisation occurred) (Bidgood et al., 2010; Meyer et al., 2004;

Moynahan & Strømgren, 2005), and four were pre–post designs (Hanselman, 2001;

Humphrey & Brooks, 2006; Singh et al., 2007; Williamson et al., 2013).

Of the RCTs/controlled trials, six had a no intervention/waitlist control

(Bidgood et al., 2010; Farrell et al., 2003; Langeveld et al., 2012; Meyer et al., 2004;

Puskar et al., 2009/2015; Robinson et al., 2002), one had treatment as usual (TAU)

(Cheng et al., 2008), three had an active control/comparator group (Herrmann &

McWhirter, 2003; Martsch, 2005; Thomaes et al., 2009), and three had a mixture of

intervention and control groups (Down et al. 2011; Kliewer et al., 2011; Yeager et

al., 2013). In the Moynahan & Strømgren, (2005) study it was unclear what the

control group received.

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Five studies adopted a mixed methods approach (Down et al., 2011;

Hanselman, 2001; Humphrey & Brooks, 2006; Puskar et al., 2015; Robinson et al.,

2002), and the remaining 13 were purely quantitative.

Sample size

The participant numbers included in the studies varied hugely, from n=3

(Singh et al., 2007), to n=476 (Farrell et al., 2003). Across intervention and control

conditions, the 18 studies included a total of 2,754 participants, however many of the

studies suffered attrition, resulting in participants failing to provide follow-up data.

Seven studies had an initial sample of less than 40 (Down et al., 2011; Hanselman,

2001; Humphrey & Brooks, 2006; Moynahan & Strømgren, 2006; Robinson et al.,

2002; Singh et al., 2007; Williamson et al., 2013).

Target population

Seven studies recruited a sample from the general school population (Farrell

et al., 2003; Kliewer et al., 2011; Langeveld et al., 20123; Meyer et al., 2004; Puskar

et al., 2009/2015; Thomaes et al., 2009; Yeager et al., 2013); six included a targeted

population of students in school (Bidgood et al., 2010; Hermann & McWhirter, 2003;

Humphrey & Brooks, 2006; Robinson et al., 2002; Singh et al., 2007; Williamson et

al., 2013), and three included clinical/higher risk populations (Cheng et al., 2008;

Down et al. 2011; Martsch, 2005). One study used more than one recruitment route

(school or local psychiatry services; Moynahan & Strømgren, 2005), and one study

inconsistently reported how the young people were recruited for the intervention

(Hanselman, 2001).

Gender

3 Exact recruitment route for this study was unclear, however it does specifically state that school students were not referred due to behavioural difficulties.

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The larger studies (n > 100) tended to have an approximately even balance of

both genders, with the exception of Cheng et al. (2008) who reported a sample of

approximately two-thirds males. The smaller studies (n < 100) were predominantly

male, with the exception of Moynahan and Strømgren (2005) who had more females

(n = 9) than males (n = 5). All but two of the studies (Martsch, 2005; Robinson et al.,

2002) included both males and females. Several studies did separate male and female

data in some of their analyses (Farrell et al., 2003; Humphrey & Brooks, 2006;

Kliewer et al., 2011; Langeveld et al., 2012; Singh et al., 2007; Thomaes et al.,

2009).

Age

Studies included participants ranging in age from 11-18, although all studies

had a minimum mean age of 13, where reported. Average ages tended to reside in the

13-14-year-old groups, with eight studies falling in this category (Cheng et al., 2008;

Down et al., 2011; Farrell et al., 2003; Humphrey & Brooks, 2006; Meyer et al.,

2004; Robinson et al., 2002; Singh et al., 2007; Thomaes et al., 2009). Four studies

featured adolescents with a mean age of 15 and above (Martsch, 2005; Moynahan &

Strømgren, 2005; Puskar et al., 2009/2015; Williamson et al., 2013), whilst two

studies failed to report an average age, instead reporting ranges of 14-17

(Hanselman, 2001) and 14-16 (Yeager et al, 2013). Four studies reported school

grades rather than ages; Bidgood et al. (2010) included 7th - 8th graders (equivalent of

ages 12-14), Herrmann and McWhirter (2003) included 7th - 9th graders (equivalent of

ages 12-15), Kliewer et al. (2011) included grade 7 (equivalent of age 12-13)4, and

Langeveld et al. (2012) simply stated “secondary school”, which starts from age 13

in Norway where this study was conducted.

4 This study was included to err on the side of inclusivity with regard to the minimum age of 13.

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Ethnicity

Five studies systematically recorded an ethnically diverse sample. Ethnicities

identified included Hispanic, “Anglo”, African American, Black, African, Black

British, Latino, Mixed Race, Caucasian, White, White British, Latino, Asian

American, and “Other” (Herrmann & McWhirter, 2003; Humphrey & Brooks, 2006;

Robinson et al., 2002; Williamson et al., 2013; Yeager et al., 2013). Five studies

consisted of predominantly (Martsch, 2005; Puskar et al., 2009/2015; Thomaes et al.,

2009), or entirely (Hanselman, 2001; Singh et al., 2007) White/Caucasian

participants. Three studies consisted of predominantly African American or Black

participants (Farrell et al., 2003; Kliewer et al., 2011; Meyer et al., 2004). Four of the

studies failed to record information on ethnicity (Cheng et al., 2008; Down et al.,

2011; Langeveld et al., 2012; Moynahan & Strømgren, 2005), and one only did so in

an anecdotal manner (Bidgood et al., 2010).

Setting

The larger studies tended to be based in schools (Bidgood et al., 2010; Farrell

et al., 2003; Herrmann & McWhirter, 2003; Kliewer et al., 2011; Langeveld et al.,

2012; Meyer et al., 2004; Puskar et al., 2009/2015; Thomaes et al., 2009; Yeager et

al., 2013) with the exception of Cheng et al. (2008) which was a mentoring scheme

based in the community. The smaller samples were from a range of contexts

including schools (Moynahan & Strømgren, 2005; Robinson et al., 2002; Williamson

et al., 2013; Singh et al., 2007), community mental health settings (Down et al.,

2011; Martsch, 2005), and one study included a one-off session in a local prison

(Hanselman, 20015).

Geographical location

5 It is unclear where the remaining sessions took place, but it appears to be in a community setting.

24

The majority (12) of the studies were based in the USA (Cheng et al., 2008;

Farrell et al., 2003; Hanselman, 2001; Herrmann & McWhirter, 2003; Kliewer et al.,

2011; Martsch, 2005; Meyer et al., 2004; Puskar et al., 2009/2015; Robinson et al.,

2002; Singh et al., 2007; Williamson et al., 2013; Yeager et al., 2013), however

within these there was diversity of geographical location, and thus likely diversity

within the religious and political ideologies of the populations. Two studies occurred

in the UK (Down et al., 2011; Humphrey & Brooks, 2006), two were based in

Norway (Langeveld et al., 2012; Moynahan & Strømgren, 2005), and one in each of

the Netherlands (Thomaes et al., 2009) and Canada (Bidgood et al., 2010).

Outcome measures

Versions of the State-Trait Anger Expression Inventory (STAXI; Spielberger,

1991) were the most commonly used measures, appearing in 4 of 19 studies (Down

et al., 2011; Herrmann & McWhirter, 2003; Puskar et al., 2015; Robinson et al.,

2002), however over 50 different outcome measures were used across the studies.

This was predominated by other questionnaire-based measures that explored an array

of outcomes, including (but not limited to) anger (e.g. Novaco Anger Control

Inventory; Novaco, 1975), “problem behaviours” (e.g. Child Behaviour Checklist

[CBCL]; e.g. Achenbach, 1991a), self-esteem (e.g. Self-Image Profile for

Adolescents; Butler, 2001), and attitudes (e.g. Attitudes towards Guns and Violence

Questionnaire; Shapiro, Dorman, Burkey, Welker, & Clough, 1997). Qualitative data

included interviews (Cheng et al., 2008; Down et al., 2011; Humphrey & Brooks,

2006; Robinson, Smith & Miller, 2002) and observations (Hanselman, 2001;

Humphrey & Brooks, 2006), but will not be discussed here.

Several of the studies used non-standardised outcome measures. In many

cases, this was school records/teacher reports of “poor behaviour” (Farrell et al.,

25

2003; Herrmann & McWhirter, 2003; Singh et al., 2007; Yeager et al., 2013). Others

included recidivism rates (Martsch, 2005), author devised questionnaires (Bidgood et

al., 2010; Meyer et al., 2004), narrative descriptions of progress (that were not

subject to formal analysis) (Hanselman, 2001), knowledge tests related to the

intervention (Farrell et al., 2003; Robinson et al., 2002), anecdotal participant

evaluations and comments (Puskar et al., 2015), mood thermometers (Hanselman,

2001), attitudinal measures (Farrell et al., 2003), experimental measures of

aggression using a computer game (Yeager et al., 2013), and peer reported

aggression levels (Yeager et al., 2013).

Whilst the majority of studies included at least two informant perspectives,

one study relied solely on self-report (Williamson et al., 2013), and one study

employed only a teacher-report outcome measure (Moynahan & Strømgren, 2005).

Seven of the studies relied on questionnaire data only.

Follow-up time scales

Six studies had no long-term follow-up, relying on post intervention outcome

measures (Bidgood et al., 2010; Cheng et al., 2008; Down et al., 2011; Hanselman,

2001; Moynahan & Strømgren, 2005; Williamson et al., 2013). Five studies provided

short – medium-term follow-up data (e.g. 4 weeks to 3 months) (Humphrey &

Brooks, 2006; Langeveld et al., 2012; Robinson et al., 2002; Thomaes et al., 2009;

Yeager et al., 2013). The remaining seven provided longer-term follow-up (5 months

- 1 year) (Farrell et al., 2003; Herrmann & McWhirter, 2003; Kliewer et al., 2011;

Martsch, 2005; Meyer et al. 2004; Puskar et al., 2009/2015; Singh et al., 2007).

Methodological/data issues

Three of the studies had particularly notable missing data/attrition at post-

test/follow-up (Farrell et al., 2003; Herrmann & McWhirter, 2003; Martsch; 2005).

26

Of the initial sample of 476 students in the Farrell et al. (2003) study, data was

available from 240 students (50%) at 6-month follow-up, and 195 students (41%) at

12-month follow-up. In Herrmann and McWhirter’s (2003) study, 207 participants

were originally recruited, however only 89 provided post intervention data and only

34 at one-year follow-up, which the authors attributed to the transient nature of such

a high-risk population. In Martsch’s (2005) study, 107 completed pre-test measures,

but only 87 completed the programme, 65 completed the entire post-test battery, and

only 31 completed entire test battery at follow up.

Two studies (Bidgood, 2010; Hanselman, 2001) failed to report psychometric

data on some of the questionnaire measures used. In addition, two studies

(Hanselman, 2001; Singh et al., 2007) did not employ any inferential statistical

analysis, relying instead on descriptive statistics. There were some instances of lack

of reporting of certain key information; e.g. Hanselman (2001) did not report results

of the “parent evaluations”, and one study failed to mention what the control group

received (Moynahan & Strømgren, 2005).

The studies will now be discussed in greater detail under the following four

categories: 1) Social/cognitive/CBT based interventions: Adolescent intervention

only; 2) Interventions with a parent component; 3) Aggression Replacement

Training6; 4) Other therapeutic modality.

1. Social/cognitive/CBT/Skills based interventions: Adolescent intervention

only

Of the 18 studies included in this review, seven were based on a

social/cognitive/CBT skills framework that focused solely on the adolescent (see

6 Whilst this intervention falls under the cognitive behavioural framework, as it is an established intervention in its own right, it has been discussed separately.

27

table 3). Within this group there were notable differences between the studies; some

included a more purist CBT group intervention (e.g. Down et al., 2011; Humphrey &

Brooks, 2006), others adopted more “lesson” based styles of teaching (Herrmann &

McWhirter, 2003; Robinson et al., 2002; Williamson et al., 2013), and others were

more integrative in their approach, incorporating aspects of emotion regulation

(Bidgood et al., 2010), and a greater emphasis on support systems (Puskar et al.,

2009/2015).

Several of these studies showed a positive effect at immediate follow-up. For

example, Down et al. (2011) compared the effectiveness of a “Personal

Development” (PD) group to a CBT based group intervention and a waitlist control

with adolescents in a CAMHS setting. Relative to the wait list control, the authors

found a significant increase in the PD group’s STAXI anger control score (d=1.58),

and, in both treatment groups, significant increases in the parent reported coping

skills (CBT: d=1.24; PD: d=1.78) and self-esteem (CBT: d=1.45; PD: d=1.07).

Herrmann and McWhirter (2003) evaluated a school-based anger management

programme including content on understanding the triggers, cognitive, physiological

and behavioural interactions that occur when angry, learning coping skills for

managing anger, and learning how to diffuse anger in others. At post-test,

improvements on measures of anger and aggression were observed in the

intervention group, although effect sizes were small (d=0.1, d=0.13, etc). However as

mentioned above, the study suffered notable attrition. Humphrey and Brooks (2006)

conducted a six session CBT intervention with 12 pupils at risk of exclusion. The

authors found promising results at their 4-week follow-up on teacher reported

measures of “total difficulties” (d=0.40), “conduct” (d=0.52), “pro-social” (d=0.62),

and “emotional” (d=0.48) domains of the Revised Rutter Teacher Scale (RRTS).

28

Robinson et al. (2002) evaluated the effectiveness of a CBT based teacher delivered

“Anger Control Curriculum” to 6th-8th grade boys (11-15 years) presenting with

emotional and behavioural difficulties. At post-test, significant improvements were

noted on self and teacher reported measures of anger and behaviour problems (effect

sizes ranging from d=0.68-1.79).

Notable age specific effects were also observed in some of the studies. In

addition to the main effects already mentioned, Down et al. (2011) found in their

CBT group, older adolescents improved more on the anger control measure

(age/outcome correlation r=0.74), whilst in the PD group it was the younger

adolescents who tended to make the greatest improvement (age/outcome correlation

r=-0.58). Bidgood et al. (2010) evaluated their “emotion management” programme in

children and adolescents from grade 1-8 (approximately age 6-14 years) who were

referred by the school or parents for having difficulties managing emotions

(primarily anger). The programme focused on training young people in skills to

manage emotions, with a significant focus on anger, as well as self-awareness of

emotions, triggers, etc. At post-test, no significant improvements were observed on

parent, teacher and child reported measures or behavioural and emotional symptoms

for children in grades 7-87, however non-significant improvements were observed on

some of the parent report measures for this age group, e.g. on total scores on the

emotional and behavioural difficulties scale (d=0.31).

Some studies produced mixed/less positive findings. Williamson et al. (2013)

piloted their 30 lesson “Positive Life Changes” intervention with a group of

adolescents already identified as at risk of exclusion from mainstream school. The

intervention occurred over 6 weeks, and included workbook homework tasks. At

7 Improvements were noted for younger children, but are not discussed here as this is outside the remit of this review.

29

post-test, significant decreases were found in participants’ propensity for physical

and verbal aggression (as measured by the “What would make you fight?” scale), but

not in actual levels of self-reported aggressive behaviour. Puskar et al. (2009)

implemented “Teaching Kids to Cope with Anger”; an eight-session programme in a

rural school in Pennsylvania. The programme focused on skills training for approach

and avoidant coping, and is grounded in a cognitive coping and stress framework.

The authors completed one-year follow-up of the participants but found no

significant changes in their responses on measures of coping. In a separate

publication, Puskar et al. (2015) provided evaluation of the programme using the

STAXI-2, but found no significant differences between treatment and control on 11

of 12 subtest measures (one reached marginal significance). Descriptive data

suggested that the overall scores of the intervention group followed a similar pattern

to the control group. More positive results were found from informal measures, e.g.

participant evaluations. The reported change may have been reduced by not selecting

“at risk” adolescents as the sample was a volunteer sample from a general school

population, as opposed to a psychiatric population.

Of those who collected follow-up measures, little maintenance of changes

was found. Attitudes towards guns and violence was the only significant change

observed by Herrmann and McWhirter (2003) that was maintained at one-year

follow-up. However there was a continued non-significant decline in state anger,

whilst trait anger remained lower than at pre-test. Puskar et al. (2009/2015) did not

observe any significant changes at post- or follow-up time points. Robinson et al.

(2002) found only one significant change was maintained at 4-week follow-up (the

intervention group was still significantly better than the control on the “anger

control” measure, d=0.88), although a non-significant improvement was maintained

30

at follow-up on the “anger-in” measure in the intervention compared to control

group. In addition, “angry temperament” remained significantly lower at post-test

before applying a Bonferroni correction. Humphrey and Brooks (2006) had more

positive results; whilst the improvements on “total difficulties” on the RRTS noted at

post-test were not maintained at follow-up, subscale changes were maintained

(d=0.48-0.62).

Studies also provided observations and suggestions for development. Puskar

et al. (2009/2015) suggested incorporating more “technology” (e.g. social media or

“virtual” Skype groups) in interventions for today’s computer-literate youth. The use

of a workbook to guide the intervention was used in Williamson et al.’s (2013) study;

this is appealing as it could allow interventions to be delivered more widely.

Herrmann and McWhirter (2003) suggested that the inclusion of booster sessions

may be a useful addition to programmes as this may help with maintaining any initial

treatment gains.

Limitations of these studies included small sample size (Down et al., 2011;

Williamson et al., 2013), attrition (Herrmann & McWhirter, 2003), lack of control

group (Williamson et al., 2013), lack of breadth of outcome measures used

(Humphrey & Brooks, 2006; Puskar et al., 2009/2015; Robinson et al., 2002;

Williamson et al., 2013), lack of long-term follow-up (Bidgood et al., 2010; Down et

al., 2011; Humphrey & Brooks, 2006; Robinson et al., 2002; Williamson et al.,

2013), failing to report psychometric properties of measures (Bidgood et al., 2010),

and some difficulties implementing studies in natural settings. For example,

Herrmann and McWhirter (2003) reported that the behavioural measure employed

(school records, e.g. detentions) was not consistently recorded.

31

In summary, there are clear beneficial effects of CBT-based programmes

immediately post-treatment, however the benefits are not always maintained longer-

term.

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Table 3 Summary of Social/cognitive/CBT/Skills based interventions: Adolescent intervention only

Author /Date / Country

Aim of study Study design Participant information

Measures Intervention Outcome Limitations

Down et al. (2011)

UK-based study

To compare the efficacy of, and preferences for, two different anger management interventions for adolescents. Specifically, CBT v a Personal Development (PD) group.

Quasi experimental design: Treatment = PD group v active control (CBT) v waitlist control. Participants were randomly allocated to either of the intervention groups; as they were oversubscribed, an additional waitlist control was created.

Mixed methods.

33 adolescents and carers involved in a CAMHS service took part. 25 adolescents provided pre- and post- data. 16 males and 9 females participated.

Exact referral criteria were not stated.

Mean age of adolescents ranged from 13.02-13.79 years across the conditions (Range = 12-16 years).

No other demographic information provided.

Quantitative: Anger expression scale of the STAXIa, the “Profile of Anger Coping Skills” (PACS)b, and the Self-Image Profile for Adolescents (SIP-A)c

All of the above were completed by the adolescents, and the PACS was also completed by a parent.

Measures collected pre- and post-.

Qualitative: Participants from each treatment condition took part in a semi-structured

10 x 90 minute CBT versus “Personal Development” (PD) group versus waitlist control. PD group aimed at enhancing the adolescents’ motivation to change by encouraging a more pro-social identity.

PD group: Relative to waitlist controls, PD group showed significant improvements in their STAXI-control (d=1.58), PACS (d=1.78) and SIP self-esteem (d=1.07) scores.

CBT group: Relative to waitlist controls, CBT group showed significant improvement in their PACS (d=1.24), and SIP self-esteem (d=1.45) scores.

Age correlation: Older adolescents improved significantly more in the CBT group (r=0.74), whilst there was a tendency for younger adolescents to improve more in the PD group (r=-0.58).

Small sample, lack of long-term follow-up, questions over treatment integrity, lack of researcher / facilitator blinding.

33

interview, which was subject to IPA.

Herrmann and McWhirter (2003)

USA based study (Arizona).

To investigate the effectiveness of the Student Created Aggression Replacement Education (SCARE)programme. Specifically, the researchers wanted to investigate differences in anger and aggression between those who completed the programme compared to those who did not undertake the programme.

Experimental design. Intervention (SCARE programme) v active (vocational educational programme) control. Cluster randomisation at school level (two schools participated; one=intervention, one=control).

Quantitative.

207 students initially recruited. Total participants at post-test = 89 (67 males), and 34 at year-long follow-up.

Specific ethnicity data not available, but ‘approx.’ “50% Hispanic, 40% Anglo, 5% African American, 5% other”.

Sample identified as academically and behaviourally at risk.

Exact ages not provided but approximate age range is 12-15 years, given school grades.

Anger = STAXIa

Aggression = MPRId (Missouri peer relations inventory; child and parent reports); AGVQe (attitudes towards guns and violence; child report), and detention records.

One year follow-up.

SCARE programme versus active control. SCARE = devised from suggestions from students and a "meta-theoretical" approach focusing on anger management and coping skills. 15 different sessions delivered for an hour twice a week. Focused on a) recognizing anger and violence in the community; b) managing and reducing self-expressions of anger; c) defusing anger and violence in others.

Anger: State and trait anger were significantly lower in the intervention group compared to control group at post-test, but small effect sizes (d=0.1).

Aggression: Only the AGVQ was statistically different between groups at post-test (lower in SCARE group), but the effect size was small (d=0.13).

At one-year follow-up, no significant differences were found on anger measures between groups, however the AGVQ was still significantly lower in the SCARE group.

Significant attrition / small N at follow-up. MPRI poorly completed and only limited reliability / validity data available at time of use. Behavioural measure unhelpful at follow-up (inconsistently recorded by school).

Humphrey and Brooks

To evaluate the

Single group phase-change

Students at risk of anger-related

The Revised Rutter Teacher

4 weeks (6 x 1-hour sessions)

Quantitative: For ‘total difficulties’, significant

Small sample (n=12), only one

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(2006)

UK-based study (inner city school).

effectiveness of a short-term CBT intervention for anger in reducing difficult school-based behaviours. In addition, the researchers aimed to explore what factors helped or hindered participants to progress in such an intervention.

(ABA) design. No control group; instead 4-week baseline, followed by intervention, followed by 4-week follow-up.

Mixed methods.

exclusion nominated by teachers.

8 males, 4 females, aged 13-14 (mean=14 years 2 months).

Mixture of Black British (7), African (2) and White British (3).

Scale for School Age Children (RRTS)f.

4-week follow-up.

Naturalistic non-participant observations and semi-structured interviews with participants.

CBT anger management programme. Main elements: Cognitive and behavioural components of anger, and using solution-focused techniques.

declines were observed at post treatment (d=0.40), but were not maintained at follow-up. However, sub-scales of ‘conduct’, ‘emotional’ and ‘prosocial’ showed positive results.Prosocial: Improvement from baseline to post intervention, maintained at follow-up (d=0.62).Conduct: Same pattern as prosocial, d=0.52.Emotional: Same pattern as above, d=0.48. No significant differences found for inattentive / hyperactive subdomain..

quantitative outcome measure (no self-report / parent report), short follow-up, lack of control group (compared to own baseline), lack of blinding for raters. Convenience sample (lack of randomisation). “Disproportionate” representation of black people.

Robinson et al. (2002)

USA based study.

To understand the impact of a CBT-intervention for anger on problem behaviours presented by “middle school” students. In addition, the researchers wanted to explore

Experimental: CBT intervention v no intervention control group. Cluster randomisation; one class from each school randomised to either treatment or control.

Mixed methods.

11-15-year-old (primarily 13-14 year olds, but mean ages not provided) male students identified as having ‘emotional and behavioural difficulties’.

3 schools recruiting a total of 41 students.

CBCLg (teacher report) and STAXIa (self-report).

4-week follow-up.

Knowledge recall tests.

A subsample of teachers (n=4) and students (n=9) were also interviewed to

Cognitive behavioural intervention taught by teachers. 10 sessions, twice per week for 50 mins each, followed by 5 practice sessions once a week.

Quantitative: At post-test, significant differences were found between several of the self-report STAXI scales and the teacher reported CBCL scores, favouring treatment over control (d ranged from 0.68-1.79). At 4-week follow-up, the only element that that showed a sustained significant improvement over the control was the "anger control" scale (d not

Short follow-up, lack of behavioural measures of anger/aggression, lack of blinding, small sample (41), no parent involvement, lack of active control

35

teacher and student perceptions of the intervention.

Mixture of white (n=14), black (n=24) and Hispanic (n=3) youth. IQ > 80.

ascertain their perception of the intervention.

provided but calculated using [mean 1-mean2] /mean SD = 0.88).

William-son et al. (2013)

USA based study.

To pilot the “Positive Life Changes” (PLC) intervention; a CBT intervention for at-risk adolescents aimed at reducing aggression and promoting social competence.

Pre-post design (no control group).

Quantitative

31 participants, 29 males 2 females from an urban, Southern California “alternative” high school (all participants had been expelled frompublic school).

Exact referral route unclear, but participants were offered “credit” towards their required school counselling hours if they attended, and were excluded if in substance misuse treatment or had already met their required counselling hours.

Mean age = 15.64

“What would make you fight” scaleh which includes scales on physical aggression propensity and verbal aggression propensity, “Self-report of behaviour” scalei to measure frequency of aggressive behaviour, and “Core Competency Survey”j which includes five subscales: positive sense of self, self-control, decision-making, moral beliefs, and prosocial connectedness.

PLC is a cognitive-behavioural group intervention to prevent adolescent aggression, grounded in a social information-processing model of cognition. Includes workbooks to guide each session.

Significant increases were observed in participants’ decision-making (d=0.43), sense of self (d=0.41), and moral beliefs (d=0.40), as well as decreases in propensity for physical and verbal aggression (d= 0.57 and 0.54 respectively). No significant differences in actual levels of aggressive behaviour, or in levels of self-control or pro-social connectedness.

Small sample (31; 29 were male, and only 27 completed the group), lack of control group for comparison, measures not well-known (although good psychometric properties reported); self-report only; no long-term follow-up

36

years (range 14-18)

Latino (51.6%), followed by mixed race (25.8%), African American (19.4%), and Caucasian (3.2%).

Bidgood et al. (2010)

Ontario, Canada.

To evaluate the Supporting Tempers, Emotions and Anger Management (STEAM) intervention for primary school-age and adolescent children. The researchers aimed to explore self, parent and teacher-reported changes in emotion management.

Largely a pre-post design, but also included an intervention v waist-list control component. No randomisation. Small waitlist control group, so some between group comparisons, but largely pre-post comparisons.

Quantitative.

143 children. Participant demographics were not reported; anecdotally there were a mixture of genders in each group and the sample was predominantly white.

Grades 1 – 8 (different intervention for grades 7-8). Specific ages not provided but range is approximately 6 – 14 years, with grades 7 and 8 being approximately 12-

Outcomes were measured on the Behavioral and Emotional Rating Scalek – parent and teacher versions. These assess strengths in the domains of: interpersonal, intrapersonal, school functioning, affective strength, and family involvement.

Author devised child self-report measure of “ability to handle emotion”.

STEAM: A school based programme combining emotion management and anger management. Emphasis on self-awareness and skills to express emotions. Significant focus on skills for managing anger specifically. 12 x 90 minute weekly sessions at local youth centre. Programme slightly different for 1-6 and 7-8 grades. Students were assigned

No significant improvement on parent, child or teacher reports in children in grades 7-8. Some non-significant improvement, particularly on parent measures (e.g. “total” score on the emotional and behavioural rating scale improved; d=0.31).

Younger children did show improvements but results are not reported here due to being outside the remit of this review.

Lack of randomisation, small number of older children (n=18 for 7th and 8th grades). Little demographic information available. Programme possibly too inclusive as some referral questions seemed anger related, others depression related. Children were interviewed for suitability - possible selection bias. Very broad age range - programme trying to catch all. No

37

14 years.

Teachers referred children whom they thought would benefit from the programme. Parents also given opportunity to refer. Broad referral criteria, e.g. “does your child hit or explode if angry?” “does your child seem sad or depressed?”, although most children referred for anger issues.

Sample from 5 schools.

(not randomly) to intervention or wait-list.

Parents were given the opportunity to attend three voluntary parent training sessions.

mention of facilitator training; measures used were incomplete (lots of missing data), one measure had no psychometric properties; no blinding; lack of long-term follow-up.

Puskar, et al. (2009)

USA based study.

To explore rural adolescents’ coping responses before and after a behavioural intervention

Quasi Experimental: Intervention v control. Randomisation of volunteer sample. No mention of what control group

179 participants in 9th -11th grade (14–18 years, mean = 15.61). Students from a “mainstream” high school in a rural area of Pennsylvania.

Adolescents coping skills measured via The Coping Responses Inventory-Youth Forml; assesses how adolescents cope with stressful life

“Teaching Kids to Cope with Anger” (TKC-A). TKC-A targets anger as a symptom, highlights violence as a potential

No significant differences were found in coping responses at any of the time points between intervention and control group.

Adolescents were not "at risk", limited outcome data - no measures of anger. Lack of behavioural- or third-party-report measures. Lack of

38

for anger. received.

Quantitative.More females (52.51%, n=94) than males (47.49%, n=85).

Mostly white (86%, n=154).

Volunteer sample from general school population.

experiences (e.g. approach or avoidance coping).

Measures administered at baseline, eight weeks post-intervention, six months post-intervention, and 1-year post-intervention.

consequence, and focuses on skills training based on a theoretical framework of cognitive coping and stress. Encourages support from wider networks. TKC-A specifically targets difficulties experienced by youth growing up in rural environments (e.g. coping with long geographic distances, lack of social support, etc). 8 x 45-min sessions.

parent inclusion in programme. No mention of what control group received. No mention of blinding. Limited applicability due to "rural" component of programme.

Puskar et al. (2015)

USA based study.

To evaluate the efficacy of the TKC-A intervention in rural adolescents on self-report measures of anger experience and anger

Experimental: Stratified randomisation by age and gender into intervention v no-intervention control.

Largely quantitative,

179 participants from general school population.

53% females, 46% males.

Ages ranged from 14–18 years (mean=15.61 years).

STAXI-2m (not including trait anger) used at baseline, post, 6-months post, and 1-year post.

Informal measures: (1) participants’ evaluations; (2)

TKC-A: Once a week for eight sessions. Groups consist of two main components 1) Psycho-educational about anger, cognitions, coping, etc.; 2) Skills practice – including role

No differences between treatment and control group on 11 of 12 STAXI-2 subtest measures; one (Anger index=general score of expressed anger) reached marginal significance after Bonferroni correction.

Participants, school staff

Only one self-report formal outcome measure, non-intervention control, participant sample not targeted for anger problems per se, not clearly reported within-group effects

39

expression. although included some informal, supplementary qualitative information.

86% White, non-Hispanic.

Participants from 3 rural south-Western Pennsylvanian schools.

anecdotal notes; and (3) mural comments.

play, practicing cognitive restructuring, etc. Programme is accompanied by workbooks including between-session practice activities. Participants completed murals in the final session to demonstrate what they had learned.

and family members completed positive evaluations; e.g. 100% thought it was applicable to daily life, and 94% gave it an overall rating of fair to excellent.

(brief mention at start of results section). No blinding; no intervention control; possible diffusion of treatment within school; lack of other quantitative measures - e.g. teacher / parent report, could have used more systematic qualitative information.

a. Spielberger (1991); b. Willner, Brace, and Phillips (2005); c. Butler (2001); d. Borduin, Blaske, Treloar, and Mann (1989); e. Shapiro et al. (1997); f. Rutter (1967); g. Achenbach (1991a); h. Chan and Henry (2009); i. Farrell, Danish, and Howard (1992); j. Gardner, Williams, Guerra, and Walker (2011); k. Epstein and Sharma (1998); l. Moos (1993); m. Spielberger (1999)

40

2. Interventions with a parent component

Three of the studies included some reported parent involvement with the

programme, over and above completing outcome measures (see table 4). All three

studies included some reference to cognitive theory in their theoretical basis; Martsch

(2005) evaluated a CBT-based intervention, Hanselman (2001)’s intervention

included elements of CBT and attachment theory, and Cheng et al. (2008)’s

intervention was based on social cognitive theory. In addition, the three studies had a

similar degree of parent involvement; Martsch (2005) invited parents to two sessions,

Cheng et al. (2008) included three parent sessions within their programme, and

Hanselman (2001) supplemented their intervention with three parenting sessions.

Beyond these similarities, the three studies were quite different in their approach.

Martsch (2005) focused on whether the group process (high versus low

process) was an influential factor on outcomes in adolescent males who had been

court ordered to attend an aggression treatment programme. The high process group

involved more engagement from group members, with greater focus on group

cohesion, interaction and members taking responsibility for their experience in the

group. The low process group was more didactic and skills focused. In contrast,

Cheng et al. (2008) evaluated a mentoring programme for young people who had

been assaulted. The programme focused on skills training and consisted of six

sessions over 2-6 months. Hanselman (2001) investigated the role of dogs in therapy.

The author described a group anger management intervention that draws on both

CBT and attachment theory. The 10-session programme was supplemented by the

parenting sessions and a one-off “scared straight” session in a prison.

Cheng et al. (2008) observed some benefits of the intervention, with

41

significantly reduced “misdemeanours” and physical aggression in the intervention

group, when treatment adherence was considered. Furthermore, trends for

improvement were noted when comparing the intervention and control group in

regard to number of fights and fight-related injuries. The comparison group’s

“treatment as usual” may have diluted treatment effects.

Martsch (2005) found no significant main effects, however significant

differences between the two groups based on age were observed. Older adolescents

in the high-process groups fared better on parent measures of conduct disorder and

on self-reported parent/adolescent conflict compared to their same age low-process

peers. The opposite pattern was found for younger adolescents (younger adolescents

in the low-process treatment groups improved significantly more than their high-

process counterparts on these same two measures). Conversely, younger adolescents

in the high-process group improved more on measures of carelessness and

impulsivity compared to their low-process same age peers whilst, again, the opposite

was found for older adolescents. Whilst causal assumptions cannot be made due to

the lack of control group, both groups showed very little recidivism rates at post-test

(2 of 65 participants) and follow-up (3 of 31). The study did however suffer

difficulties with attrition (as described earlier).

Hanselman (2001) reported reductions in scores on measures of anger,

however these results should be interpreted with caution due to several

methodological difficulties. This included a small sample size (n=7), lack of control

group, lack of inferential statistics, lack of reporting psychometric data, inconsistent

reporting of some information (e.g. referral route), failing to report parent evaluation

data, and over-reliance on unstandardised descriptions of progress. The author also

offered many inferences, interpretations, and evaluations throughout the paper,

42

which lacked robust explanations (see table 4 for examples).

Given the diversity of the studies within this category, and the

methodological issues present in the Hanselman (2001) study, it is difficult to draw

conclusions about any added value of an additional “parenting” component.

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Table 4

Interventions with a parent componentAuthor/ Date / Country

Aim of study Study design Participant information Measures Intervention Outcome Limitations

Martsch (2005)

USA-based study.

To compare the effectiveness of two cognitive-behavioural interventions for aggressive behaviours in adolescent males; a “high process” group in which group process and cohesion is emphasised, versus a more instructional “low process” group.

Experimental: Stratified random assignment of individuals to one of two interventions (treatment 1 v treatment 2). No neutral “control” group.

Quantitative.

107 completed pre-test measures, 87 completed programme, 65 completed entire post-test battery, 31 completed entire test battery at follow-up.

Separated by age (12.9-14.9 years versus 15-18.3 years) and then randomly assigned. Mean overall age = 15.96 years.

Court referred male adolescents in Wisconsin who have problems with aggressive behaviour.

Of the 65, 54 (83.1%) Caucasians, 9 (13.8%) African Americans, and 2 (3.1%) Hispanics.

Parents also invited to two group sessions.

Recidivism rates

Behaviour ratings: Revised Behaviour Problem Checklista - conduct disorder and socialized aggression scales (parent report).

Anger control: Novaco Anger Inventoryb (Self-report)

Social skills: Teenage Inventory of Social Skillsc

Social problem solving; Subscales of the Social Problem Solving Inventory – Revisedd.

Parent-adolescent conflict: Conflict Behaviour Questionnaire (teen and parent versions)e.

Outcomes measured at pre-test, post-test and follow-up (9 months later).

Comparison of two cognitive behavioural therapy interventions - low process versus high process. The low-process was more focused on teaching specific cognitive- behavioural skills. The high-process condition featured more emphasis on group cohesion, interaction, and participation. 2 hours per week for 10 weeks.

Results analysed at group level, therefore n=16 rather than 65.

No significant main effects.

Significant improvements in participant-reported conflict behaviour at post-test only. Not supported by parent report.

Age X group effects: Older adolescents improved significantly more in the high-process groups on parent reported levels of conduct disorder and, at post-test, on self-reported parent/adolescent conflict, when compared to their same age peers in the low process groups. The younger adolescents

Differential findings on treatment integrity, limited range of reporting perspective, high level of attrition at follow-up, no effect sizes reported.

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in the low-process treatment groups improved significantly more on these same two measures, when compared to their same age peers in the high process groups.

Opposite pattern for impulsivity/carelessness (older adolescents improved significantly more in low-process; younger adolescents better in high-process.

Cheng et al. (2008)

USA based study.

To evaluate the effectiveness of a mentor-implemented violence prevention intervention for adolescents who have presented to the Emergency Department following assault injury.

Experimental: Intervention V TAU. Randomised. Comparison condition received standard case management services.

Quantitative.

Participants identified via those who presented to the emergency department following assault injury aged 10-15 years (mean=13 and 12.9, intervention and comparison).

113 (of 166) completed post treatment data.

Sample was 2/3rds male. No further demographic information provided.

Urban hospital sample in Baltimore.

Outcomes focused on self -efficacy regarding violence and risk factors for violence. Data gathered via a mixture of questionnaires and survey/interview data.

Self-report: Items taken from Slaby’s Attitude about Interpersonal Violence Scalef,g, and the Perception of Environmental Violence Scaleh, i. Questions asked about social competence, conflict avoidance self-efficacy, history of fighting and weapon carrying (latter from the Youth Risk

Mentoring programme that consisted of 6 sessions over 2-6 months with adolescents, and 3 parent sessions. Sessions were “violence prevention” focusing on skills building and based on a social-cognitive framework.

A significant reduction in “misdemeanour activity” was found in intervention group, compared to control group (rate ratio=0.29), as well as an increase in self-efficacy. Interestingly, the low-treatment-adherers reported significantly higher self-efficacy than the high adherers.

Compared to control, he high-treatment-adherers group showed decreased physical aggression (rate ratio=0.51)

Lots of non-significant results, including youth reports of fighting and weapons carrying in the last 30 days, parent report of youth aggression, social competence and attitudes about retaliation. Some intervention present in comparison group. Lack of follow-up = unknown if

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Behavior Surveyj), their recent “misdemeanours” (e.g. property damage), friends’ problem behaviours, and their physical aggression..

Parent report: Aggression subscale of the CBCLk.

Interviews occurred at baseline and post treatment (6 months).

misdemeanours (rate ratio=0.09).

Majority of measures non-significant.

“trend” for effects would be sustained when mentoring relationship ceased. No behavioural measures.

Hansel-man (2001)

Explicit location of the group is not stated, but other references suggest a USA-based study, likely in New Jersey.

To describe a CBT and attachment informed group anger intervention for adolescents which incorporates the use of animals in therapy sessions.

Pre-post design (no control group). Author refers to the study as an ABA design, however there doesn’t appear to be a baseline period.

Mixed methods.

5 males, 2 females, aged 14–17 years.

Inconsistent reporting of nature of referral process; adolescents either applied through a newspaper or were advised by school to attend; however elsewhere article also states that courts referred adolescents.

Caucasian.

No mention of number of parents present.

Quantitative: State-Trait Anger Scale (STAS)l; Companion animal bonding scale (CABS)m, Beck Depression Inventory-IIn - all pre/post – unclear exact time points.

Mood thermometers (beginning and end of each session).

Qualitative: Parent evaluations of children’s abilities to work through their anger.

Narrative description provided on participant’s progress from facilitator.

Intervention: Combination of CBT and attachment, including having dogs in many sessions. 10 group sessions, 3 parent sessions, and a “scared straight” session in a prison, as well as a “guest speaker” (a well-known boxer who talked about his history of anger difficulties and how he now managed this).

No outcome information on parent evaluations.

Only means and standard deviations calculated.Authors reported a "significant decrease in the state anger and trait anger" but provided no p values/effect sizes, and a "significant” increase in CABS scores during companion animal bonding but again only provided means/sd.

BDI-II means increased; author explanation: "A significant increase in depression would be explained by the lack of use of drugs and alcohol

Author makes conclusions that are based on very little evidence due to lack of appropriate statistics (no inferential statistics or effects sizes). Author appears to have been group facilitator therefore significant bias in conclusions may be present (although doesn't actually say who facilitated). Author makes unsubstantiated

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during therapy. The adolescent becoming anxious and vulnerable because they are learning to feel. This was due to a lack of drugs in their system […]” (p.174).

Mood thermometer: "The mean scores were a significant increase in tension, confusion, anger, and depression. A significant decrease in fatigue also occurred […]" (p. 175). No p values/effect sizes.

conclusions (e.g. why depression scores may have gone up, that animals resulted in increased positive feelings) and erroneous statements (mood thermometers contradict other measures). Narrative outcome is unsystematic. Lack of parent feedback included in results / discussion. Very small sample. No mention of psychometric properties of measures. No control group. Too much of paper devoted to theory, not enough to evaluation.

a. Quay and Peterson (1987); b. Novaco (1975); c. Inderbitzen and Foster (1992); d. Maydeu-Olivares and D’Zurilla (1995) e. Prinz, Rosenblum, and O’Leary (1978) f. Slaby and Guerra (1988); g. Dahlberg, Toal, and Behrens (1998); h. Hill and Madere (1996); i. Hill and Noblin (1991); j. Whalen et al. (2003); k. Achenbach (1992); l. Not referenced by author and unable to locate reference. m. Poresky, Hendrix, Mosier, and Samuelson (1987) n. Beck, Steer, and Brown (1996)

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3. Aggression Replacement Training (ART) studies

Two studies of ART met the inclusion criteria (see table 5). Langeveld et al.

(2012) investigated the effectiveness of a 12-week ART programme in primary and

secondary school students in Norway using a sample of 112 young people.

Moynahan and Strømgren (2005) conducted a much smaller evaluation of ART; their

study included 14 children and adolescents who were referred by their schools or

psychiatry/rehabilitation services. This study included young people with ASD and

ADHD diagnoses, as well as those without a diagnosis.

Langeveld et al. (2012) showed overall positive results for improved social

competence and reduction in behavioural problems, however these results were

moderated by both age and gender. Boys and girls both improved in social

competence, but when gender was considered, no significant reduction was found in

behavioural problems for girls (of all ages). The authors explained this is likely due

to a pre-test floor effect. Younger (primary school age) participants (of both genders)

demonstrated the significant main effect described above, whilst secondary school

age participants did not. The intervention also appeared to be more effective for

those low in social competence and high in behavioural problems pre-treatment. In

contrast, null results were observed in Moynahan and Strømgren’s (2005) outcome

data. As in the Langeveld et al. study, the authors suggested this could be due to the

“normal range” scores observed pre-test. The authors also noted considerable

variation in the pre- and post-test scores for both groups (e.g. control group post-test

problem behaviour score, mean=91.57, SD=40.88), making interpretation of

outcomes difficult.

The results of both studies suggest interventions may be better targeted at

higher risk young people, whilst Langeveld et al.’s (2012) results also point to

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specific targeting of younger participants. Both studies lacked long-term follow-up of

their outcomes. In addition, Langeveld et al.’s study experienced high levels of

missing data at all time points, raising questions over the validity of the results and

acceptability of the intervention.

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Table 5Aggression Replacement Training (ART) studies

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a.

51

Author / Date / Country

Aim of study Study design Participant information

Measures Intervention Outcome Limitations

Langeveldet al. (2012)

Norway-based study.

To evaluate the possible mediating role of social competence in reducing behavioural problems in children and adolescents who have received the ART programme.

Multi-baseline experimental design: Intervention v control. Randomized to two experimental groups (delayed pre- and post-test design to provide control).

Half of the participants completed measures 4-weeks before the intervention (“pre-pre” time point), and half 4 weeks after the intervention (“post-post” time point).

Quantitative.

112 primary and secondary school pupils from 18 ART groups in Norway.

No further demographic information provided.

Not referred due to behavioural difficulties although exact referral route unclear; it appears post-graduate students and teachers may have selected students (see p.386).

Social Skills Rating Scale (SSRS)a: Measures social competence and behavioural problems and includes parent, teacher and self-reports. Domains covered include internalising and externalising problems, assertion, cooperation, self-control, parent-rated responsibility and student-rated empathy.

12-week ART programme aimed at reducing aggressive behaviours in youths. Structured programme consisting of three separate modules (social skills training, anger control training, and moral reasoning training).

Significant improvements in social competence (partial eta squared =0.23) and behavioural problems pre- to post- (partial eta squared =0.02). At “post-post” test, behavioural problems further decreased (partial eta squared=0.56).

Moderator analysesGender: Improvements for both genders in social competence, but only for boys in problem behaviours (girls = possible floor effect).

Age: Younger participants (primary) showed significant improvements on social competence measures and reductions in problem behaviours; only marginal reductions in behavioural problems for older children (secondary).

Effects also moderated by pre-treatment social competence / behavioural difficulties (complex picture).

No effect sizes for moderator analyses.

Significant number of non-responders at all time points, lack of long-term follow-up, lack of behavioural measure, no demographics provided so unclear of generalisability.

Moynahan and Stromgren (2005)

Norway-based study.

To evaluate if the ART intervention is successful at reducing problem behaviours and increasing social skills when delivered to a mixed sample of

Experimental: Intervention v control (unclear what control group received). No mention of how individuals were allocated to treatment or control.

Quantitative.

Study on adolescents and children (adolescent results only included here). 14 adolescents referred by school or local psychiatry services aged 14-20 years; 7 in ART group, 7 in control. lack

SSRS (teacher scales)a Measures social skills, problem behaviours and academic competence. Study only interested in social skills and problem behaviour subscales.

Minimum of 30 hours of ART. Enhanced components were added. 10-week course.

No significant differences found in pre- and post-test scores for the adolescents in the ART group in social skills or problem behaviours, although mean scores were within “normal range” at pre- and post-test.

Note: better results were found for children.

Using “low risk” individuals may have led to null results, very small sample, inclusion of ASD/ADHD may have influenced how group ran, lack of blinding, no long-term follow-up, lack of homogeneity

Gresham and Elliot (1990)

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4. Other therapeutic modality

Six studies did not fit into the first three categories, representing a

diverse range of approaches to managing aggression (see table 6). This

included “mindfulness” (Singh et al., 2007), an expressive writing

intervention (Kliewer et al., 2011), and a skills-based “curriculum” approach

(Farrell et al., 2003), as well as more experimental interventions. For

example, Thomaes et al. (2009) designed an intervention that was aimed at

buttressing self-esteem (i.e. protecting self-esteem from threat), as opposed to

boosting self-esteem and delivered it to 12-15 year olds in a general school

population. The intervention is aimed at individuals high in narcissistic traits,

with the underlying theory suggesting that protecting these individuals from

ego threat may reduce aggression associated with ego-threat. The intervention

consisted of a brief writing exercise that encouraged participants to focus on

their values and why they are important to them. In another unique

intervention, Meyer et al. (2004) evaluated the impact of a 12-session

multimedia curriculum aimed at reducing violence in schools. The curriculum

was based on the TRA and outcomes were measured based on the

subcomponents of the TRA via an author devised-questionnaire. Finally,

Yeager et al. (2013) focused on aggressive responses to victimisation,

comparing the effects of a six session “incremental theory” intervention to a

treatment control (“coping skills”) and a “no treatment”. The “incremental

theory” intervention taught the idea that people have the potential for change,

whilst the “coping skills” intervention taught skills on how to think positively

and cope productively in the face of victimisation or exclusion. Two of the

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studies focused on specific “types” of aggression; Thomaes et al. (2009)

looked specifically at narcissistic aggression., whilst Yeager et al. (2013)

focused on aggressive responses to victimisation.

Results were, again, very mixed in these studies. Thomaes et al.

(2009) and Kliewer et al. (2011) showed some initial promising results, but

these were no longer evident at follow-up. Meyer et al.’s (2004) within-

groups analyses at 5-month follow-up showed both groups worsening on

outcome measures, although the intervention group worsened on less

measures than the control. It is not clear whether these results were

significant or not.

More positive results were found by Singh et al. (2007), who

conducted a brief mindfulness-based intervention with three young

adolescents who were at risk of expulsion from school. The authors reported

reductions in aggressive behaviours or bullying during the “practice” phase of

mindfulness, and over the following year none of the adolescents were

excluded. Similarly, Farrell et al. (2003) found several positive results.

Following the implementation of the Responding in Peaceful and Positive

Ways sixth grade curriculum (RIPP-6), the authors conducted follow-up

research on the same schools by implementing a booster seventh grade

curriculum (RIPP-7). This 12-session programme aimed to reduce violence

by looking at communication skills, respect, valuing friendship, and conflict

resolution skills, incorporating the martial art “Aikido” as a component.

Although immediate main effects were somewhat disappointing, disciplinary

code violations for violent offenses during the eighth grade were over twice

as high in the control group compared to the intervention group. In addition,

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whilst not reaching significance, the RIPP-7 group also had less out-of-school

suspensions at 12-month follow-up (rate ratio=1.4). Furthermore, at 6-month

follow-up, significantly lower rates of non-physical aggression were reported

for boys (d=0.37) and increased attitudes supporting non-violence (d=0.27).

Regression analysis showed that at both 6 and 12-month follow-up, lower

levels of violent behaviour were reported for those with high pre-test levels of

violence in the RIPP-7 group compared to the control group. Finally, Yeager

et al. (2013) found favourable results for the incremental theory intervention,

and incorporated a range of outcome measures including an experimental

measure of aggression (d=0.47), prosocial behaviour (d=0.86), and teacher

reports of conduct problems (d=0.66). The latter measure was significantly

improved in the incremental theory group only for those who have previously

been victimised, providing support for the theoretical basis of their

intervention.

Several of the studies suffered methodological issues. For example,

Farrell et al. (2003) lost 50% of participants at 6-month follow-up, and only

41% remained at 12-month follow-up. Furthermore, differences were found

in age and grade-point average between the retained and attrited samples.

Questions around the validity/reliability of outcome measures used in Meyer

et al.’s (2004) could also be raised. Singh et al.’s (2007) research lacked

inferential statistics and relied entirely on adolescent self-report data to

confirm adherence to mindfulness practices. Other limitations of this study

included the extremely small sample, lack of control group, and concerns

over validity and reliability of outcome measures used.

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Table 6Other therapeutic modality studies

Author / Date / Country

Aim of study Study design Participant information

Measures Intervention Outcome Limitations

Thomaes et al. (2009)

Nether-lands based study.

To evaluate whether an experimental intervention aimed at protecting one’s self-esteem from threat (as opposed to boosting self-esteem) can reduce narcissistic aggression in a sample of adolescents in a “real-world” setting.

Experimental: “Randomised field experiment”. Intervention v active control.

Quantitative.

Participants were 405 12-15 year olds (mean=13.9 years) from two public middle schools within a ‘middle class’ area of the Netherlands.

52% male, 48% female.

90% = Caucasian, 10% = “other” (Turkish, Dutch Antillian, mixed).

Childhood Narcissism Scalea.

Global self-worth scale of the Self-Perception Profile for Adolescents (measuring trait self-esteem)b.

State self-esteem measured by a pictorial scale (taken from the Self Assessment Manikin)c.

Peer-nominated aggression measure (piloted in another study – see supplemental information online).

Aimed at buttressing self-esteem. Theorised that reducing the threat to self-esteem, as opposed to improving it, might reduce narcissistic aggression.

Intervention: 15-minute self-affirmation exercise in which participants wrote about their most important values and why they are important to them.

Control: Participants wrote about their least important values and why these values may be important to others.

Intervention: No significant association between narcissism and increased aggression, irrespective of levels of state self-esteem.

Control condition: Significant association between narcissism and increased aggression for students with low level state self-esteem but not high level state self-esteem.

Conclusion: Buttressing self-esteem can reduce narcissistic aggression for 1 school week. Results not present at longer-term follow-up.

Effect sizes not provided (although confidence intervals are provided).

Boys were more aggressive than girls overall.

Short-term follow-up (up to 9 weeks after initial intervention), very low treatment dosage, short-term effects (only lasted one week), intervention for narcissistic aggressive youth, not aggressive youth generally, not well known, robust outcome measures

Singh et al.

To evaluate the

Pre-post design, very

3 x 7th grade students at risk of

Non-standardised measures.

"Meditation on the Soles of the Feet":

For all three adolescents, little decline in aggressive

Very small sample, lack of inferential

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(2007)

Country of origin not explicitly stated but appears to be the USA.

effectiveness of a mindfulness intervention for adolescents with aggressive behaviour using a multiple-baseline design.

small n (n=3).

Quantitative.

expulsion. Students were aged 13, 13 and 14.

2 males, 1 female.

Caucasian.

All diagnosed with conduct disorder.

All had histories of aggressive behaviour at school and were referred for therapy from their school. High risk population; 2 had been inpatients several times and 1 had co-morbid learning difficulties8.

Baseline data: Consisted of retrospective school data on each individual's aggressive behaviour. Two weeks of teacher-reported prospective data was also collected.

Training phase and mindfulness practice phase: Teacher reported and self-reported incidences of behaviours.

Follow-up: School records were reviewed for records of incidences of expulsion or threat of expulsion.

Mindfulness intervention. Therapist met 3 x /week for 15 minutes to teach/practice intervention with young person for 4 weeks. There was then a "mindfulness practice" stage that lasted 25 weeks; the therapist only saw the young person for 15 minutes once a month. Follow-up occurred over the following school year.

behaviour or bullying was observed in the intervention phase, however “substantial” decline was observed during the “practice” phase. None of them had further threats/actual expulsion.

statistics (only percentages and means), lack of standardised outcome measures, retrospective data collection for baseline (no mention of quality of this data keeping), different measure for follow-up, unable to determine treatment fidelity (relies on adolescent self-report), self-report collected by researchers, no control group, no blinding, threat of expulsion may have been the driver for behaviour change.

Meyer et al. (2004)

To undertake a process and outcome

Quasi-experimental: Treatment v

Participants were from the general school population,

Authors devised a questionnaire based on the

12-lesson multimedia curriculum based

Results show that both groups deteriorated rather than improved, although

Lack of randomisation, lack of blinding, lack of

8 Note, paper describes the client as having comorbid learning disabilities, however quotes his IQ as 105. It is therefore assumed that the authors are describing learning difficulties, as opposed to intellectual disability.

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USA based study.

evaluation of the Get Real About Violence Curriculum in a sample of adolescents. The intervention is aimed at reducing verbal and physical aggression and behaviours that may contribute to this aggression.

no-intervention control, but no randomisation.

Quantitative – including process and outcome evaluation.

168 in experimental school, and 125 in the control school.

Age=12-14 years.

55% male, 45% female – experimental school, 50/50 control school.

Ethnicity: Majority African American (approx. 77-80% across the two schools), “white” second most represented ethnicity (approx. 7-8% across the two schools), as well as Asian, Hispanic and “other” ethnicities.

Participants from a “moderate-sized Midwestern city”.

subcomponents of the TRA (e.g. behaviours, intentions, subjective norms, etc.) and measured these in relation to verbal aggression, spreading rumours about a fight, watching a fight and fighting.

Instructors completed questionnaires indicating their perspectives on delivering the intervention and students’ response to it.

5-month follow-up.

on the theory of reasoned action (TRA). Employs a range of mediums to promote a violence prevention messages. Themes include (amongst others) addressing attitudes and norms around violence and discussing alternative ways of resolving problems that do not involve violence. Control group = no intervention.

there was less decline in the experimental group than there was in the control group, and more instances of improvement in the experimental group on some of the measures. Experimental group significantly outperformed control group at post-test on intention to spread rumours (d=0.10), intention to watch a fight (d=0.16), and 3 of 12 measures of global beliefs and opinions about fighting and violence (d=0.06, 0.30, 0.29).

Post-tests occurred at 1 and 5 months after intervention, however there was so little change observed at 1 month that only 5-month data was used.

Teachers reported positive process outcome results, rating the curriculum “quite favourably” and observed that they would be likely to teach the curriculum again.

Note all effect sizes calculated via this author using

psychometrically robust measures (although author had piloted questionnaire), very broad definition of "outperformed" i.e. may have both got worse, but intervention group worsened less, therefore possible overstating claims.

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(mean 1-mean 2) / mean SD.

Kliewer et al. (2011)

USA based study.

To evaluate the efficacy of two school-based expressive writing interventions in a sample of 12-13 years olds living in a “high violence” neighbour-hood.

Experimental: Cluster randomisation to 1 of 3 conditions (2 x intervention, 1 x active control).

Quantitative.

258 7th grade students from a general school population (although in a deprived, high-crime area). Specific ages not mentioned but 7th grade=12-13 years.

Gender: Percentage male=40-52.1%.

Ethnicity: Percentage “African American” =87.6-97.4%.

Over 90% of participants had experienced 5 or more types of “victimisation”, e.g. being threatened, being slapped, hit or punched.

Participants

Outcomes included self and teacher reported data measured at baseline, 2 and 6-month follow-up.

Self-reported aggression: Rated on the Physical Aggression subscale of the Problem Behaviour Frequency Scalesd.

Teacher reports: Rated students on the Aggressive Behaviour subscale of the Achenbach System of Empirically Based Assessmente. Teachers also rated students’ emotional lability using the subscale from the Emotion Regulation Checklistf.

Participants were encouraged to write 2 x a week for up to 20 minutes on their deepest thoughts and feelings around violence. The intervention lasted for 8 sessions over a 5-week period. 3 conditions. 1) Standard expressive writing; 2) Enhanced expressive writing where students were encouraged to not only write, but also use other ways of expression such as poetry, song, etc.; 3) Control - writing about non-emotive topics.

2-month follow-up, Teacher-ratings: Aggression/lability was lower among youth in the standard expressive writing condition compared to the control (d=0.48), and the “enhanced” writing condition (d=0.31). Participants with high levels of community violence victimisation benefited the most from the standard expressive writing intervention on measures of teacher-rated aggression lability. Participants with increasing levels of witnessing community violence increasingly benefitted from the enhanced writing intervention, whilst all students showed a positive effect for the standard writing condition (effect size not quoted but displayed graphically).

Boys and girls benefitted equally.

However, students did not report the same positive

Different teachers completed some of the follow-up data therefore may have been different styles of rating, some of the teachers were not blind to treatment condition. No data available on those who declined to participate; lack of parent-report; benefits were relatively small (lack of dose); authors suggested incorporation into a bigger intervention may be helpful.

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attended 1 of 3 urban middle schools in South-Eastern USA.

NB. Teacher rated aggression and emotional lability were combined into a composite score due to high correlations.

findings that teachers did, and the positive teacher observations were not replicated at 6-month follow-up.

Farrell et al. (2003)

USA-based study.

To evaluate the impact of the Responding in Positive and Peaceful Ways–7 (RIPP-7) curriculum in sample of students who have previously received RIPP-6.

Experimental: Cluster randomisation via class into intervention v no intervention control.

Quantitative.

476 students (10 clusters, n=239 in intervention; 11 clusters, n=237 in control). All students should have received RIPP-6 in the previous year.

Clusters consisted of “nonspecial education” classrooms.

Gender: Intervention = 118 boys and 121 girls; control = 106 boys and 131 girls.

Age at start of school year = 11.9-15.9 years (mean = 12.8

Problem Behaviour Frequency Scales - student self-reportd.

Revised Children’s Manifest Anxiety Scaleg.

Knowledge of the intervention test

Attitudes towards violence via students indicating their level of agreement with statements relating to violenceh.

School disciplinary code

RIPP-7 is a 12 (weekly) session curriculum on developing skills based on respect, communication, and valuing friendship. It involves experiential exercises, including employing techniques from the martial art of Aikido. RIPP-7 builds upon RIPP-6 (a 25 session 6th grade curriculum based on social cognition and emotional processes). The focus of RIPP-7 is more on conflict resolution skills.

Complete data only on 195 students at 12-month follow-up.

No significant differences between intervention and control post-test regarding disciplinary code violations. However, during the beginning of the following academic year (8th grade), disciplinary code violations were over twice as high in the control group than in the intervention group (significant difference, rate ratio=2.1). Pattern continued in the latter half of 8th grade, though not as pronounced.

Gender differences: Boys in the intervention reported significantly lower rates of nonphysical aggression (delta=0.37), and greater

High levels of attrition and significant differences between the attrited students and those that stayed at school; more older students and those with a lower grade point average transferred out of school. Can only interpret programme as an add-on to RIPP-6, rather than a stand-alone programme. Intervention addressed violence prevention, as opposed to anger specifically.

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years).NB: Intervention didn’t begin until February of the academic year, hence mean age would have been > 13.

Ethnicity: 97% Black or African American.

Schools in Richmond, Virginia. High levels of poverty and crime.

violations.

Where possible, data was collected at post-test and 6 and 12-month follow-up.

levels of knowledge of course content (delta=0.65). At 12 months, they reported less favourable attitudes toward the use of violence (delta=0.34).

Pre-test violence levels: Those with higher pre-test levels of violence who received the intervention had lower predicted follow-up scores. General pattern of treatment effects increasing as pre-treatment violence levels increase. Similar pattern observed for nonphysical aggression and delinquent behaviour (mixture of significant and non-significant results).

No other notable significant effects.

Conclusions: Main effects not hugely supportive, but better results for those with high pre-test scores and for boys.

Yeager et al. (2013)

To evaluate the effectiveness of an

Experimental: Intervention (incremental theory group)

230 9th and 10th graders completed the intervention (14-16 years).

Questionnaires measuring adolescents’ implicit theories

Compared effectiveness of an incremental theory intervention with a

Only 74% provided post-survey data.

Incremental theory group

Short interventions so may not be representative of all coping skills

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USA-based study.

incremental theory intervention compared to a coping skills intervention in reducing aggressive responses to victimisation.

v treatment control (coping skills) v no treatment control.

Cluster randomisation via class.

Quantitative.

Sub sample of 92, collected at 4-weeks post intervention.

Gender: 55% male, 45% female.

Ethnicity: 57% Latino, 10% Asian American, 9% African American, 17% White (non-Latino), and other.

64% of students received free or reduced price lunch.

Medium-large school in San Francisco, randomly selected from local large schools.

of personality, e.g. asked to agree/disagree with the statements about whether certain people (e.g. bullies) can changei.Baseline aggression=peer reported aggression levelsj.

Experimental computer game designed to assess level of aggression (and prosocial behaviour) in response to victimisation and exclusionk,l.Depressive symptoms via the Children’s Depression Inventorym.

Self-reported levels of peer victimisation.

3-months post

generic coping skills intervention in reducing aggression in response to victimisation and exclusion. Each intervention consisted of 6 x 50 minute sessions over 3 weeks. Interventions were similar in content, but two key differences: incremental theory intervention taught the idea that people have the potential for change, whilst the coping skills intervention taught skills for thinking positively and coping productively in the face of victimisation or exclusion.

participants assigned their victimisers significantly less hot sauce (measure of aggression) than their coping skills group peers, although not significantly less than no intervention control group. (d=0.47 when comparing intervention to two control groups combined; no further effect sizes provided.) They also wrote significantly more pro-social notes to their fictional aggressors than control groups (d=0.86).

Teachers nominated incremental theory group participants significantly more frequently for having reduced conduct problems than controls (d=0.29). This effect was further qualified by peer victimisation status; amongst those who had been victimised by peers, teachers were more likely to nominate those in the incremental theory group as having reduced their conduct problems than controls (d=0.66).

Amongst those who

interventions. Is this the most ecologically valid measure of aggression (computer game)? Short follow-up (at 3 months, only the teacher measure was used, others sooner). Perhaps too specific in its focus on type of aggression for generalisation.

62

intervention: Teachers reported on reductions in conduct problems.

experienced peer victimisation, both incremental theory and coping skills participants showed significantly less depressive symptoms post group, compared no intervention controls (d=0.60 and 0.66).

Incremental theory group participants were significantly less likely to be absent or late (d=0.27) than control groups combined.

a. Thomaes, Stegge, Bushman, Olthof, and Denissen (2008); b. Harter (1988); c. Bradley and Lang (1994); d. Farrell, Kung, White, and Valois (2000); e. Achenbach (1991b); f. Shields and Cicchetti (1995); g. Reynolds and Richmond (1978); h. Farrell, Meyer, and White (2001); i. Yeager, Trzesniewski, Tirri, Nokelainen, and Dweck (2011); j. Thomaes et al. (2009); k. Williams and Jarvis (2006); l. Lieberman, Solomon, Greenberg, and McGregor (1999); m. Kovacs (1992)

63

Discussion

The literature review has examined what research has been published since

2000 in regard to interventions for anger and aggression in adolescent males. This

review builds on previous reviews/meta-analyses by focusing on more recent

research, broadening the focus from CBT-only interventions, and focusing solely on

adolescents. On the whole, the review supports some of the earlier findings; the

literature is still predominated by a CBT approach, which tends to facilitate some

improvements, which may or not be maintained long-term. The review also included

evaluation of alternative interventions, which show some tentative support for their

effectiveness, e.g. mindfulness (Singh et al. 2007), and the skills-based curriculum

approach initiated by Farrell et al. (2003).

The review highlights that there are a number of programmes that appear to

work well for reducing anger and aggression in adolescents, at least to some extent;

e.g. Humphrey and Brooks (2006) found positive results, with effect sizes ranging

from 0.40 to 0.62. Several of the studies used a randomised controlled trial approach,

strengthening the validity of their results. In addition, the majority of programmes

used multiple informant perspectives when recording outcomes, and several

supplemented questionnaire data with more ecologically valid outcomes (e.g. school-

based behavioural measures). Furthermore, some of the researchers have explored

the characteristics of participants and discovered helpful information about the

effectiveness of programmes. For example, several studies either demonstrated

(Farrell et al., 2003; Langeveld et al., 2012) or suggested based on their findings

(Moynahan & Strømgren, 2005; Puskar et al., 2009) that interventions may be more

effective when targeted specifically at “at-risk” adolescents. Given that 7 of the 18

studies focused on a “general population”, there is clearly a need for more targeted

64

intervention for vulnerable young people. There was also a suggestion from some

studies that differentiating programmes by gender (Farrell et al., 2003) and age

(Martsch, 2005) may be helpful. Intuitively appealing adaptations and/or suggestions

for adjustments to programmes were also provided, including the use of a workbook

to structure a programme (Williamson et al. 2013), and the use of technology and

media to appeal to modern youth (Puskar et al., 2009). The use of a “higher dosage”

or additional booster sessions (as suggested by Herrmann & McWhirter, 2003) may

be helpful, as some studies have shown short-term treatment gains (e.g. Thomaes et

al., 2009). Alternatively, incorporating effective brief interventions into broader

intervention packages (as suggested by Kliewer et al., 2011) may help with

improving and/or maintaining treatment gain, and (due to their brevity) could

potentially reduce attrition.

Considering areas for future development, whilst there is evidence that CBT

can effect change, the lack of diversity in interventions is limiting. There were some

interesting “one-off” interventions that may warrant further exploration and

validation. For example, two studies (Thomaes et al., 2009; Yeager et al., 2013)

focused on specific “types” of aggression and their potential causal factors.

Classifying aggression in this way may be helpful to consider in future research; if

interventions are designed at targeting the “causes” of anger and aggression, it would

be helpful to know the “type” of aggression being targeted. This may be less relevant

for interventions targeting how individuals respond to feelings of anger.

Many of the studies in the review experienced methodological difficulties.

Critical problems included small sample size, lack of long-term follow-up, lack of

inferential statistics, attrition, and limited outcome measures. Additionally, the

variety of measures used across studies creates difficulties in making comparisons

65

between interventions. There were also incidents of authors making unsubstantiated

conclusions (e.g. Hanselman, 2001). Only five studies adopted a mixed-methods

approach; whilst the qualitative data from these was not analysed in this review, a

lack of qualitative data generally across studies could result in a fairly superficial

exploration of interventions, and a lack of clarity over what the effective mechanisms

of change are within interventions. Only two studies focused solely on boys, despite

there being evidence for differential effects of the interventions on boys and girls

(e.g. Langeveld et al., 2012). Finally, the majority of the studies (12) were based in

the USA, raising questions over the generalisability of the findings. This issue of

generalisability is further complicated by the heterogeneous populations within the

USA-based studies.

In conclusion, the literature review highlights that further research is required

in the field of adolescent male anger and aggression. Positive examples of helpful

interventions have been found (effect sizes up to d=1.79; Robinson et al., 2002), but

also a lack of volume and breadth in the twenty-first century research field. There are

historically well-established interventions for anger, based around a social-cognitive-

behavioural framework, and indeed some more recent research continuing to support

this (e.g. Humphrey & Brooks, 2006). However this approach does not produce

consistently, clear positive results (e.g. Williamson et al., 2013), and results are not

always maintained at long-term follow-up (e.g. Puskar et al., 2009/2015). In addition,

the approach is not acceptable to all, evidenced by the level of attrition experienced

in some studies (e.g. Herrmann & McWhirter, 2003; Martsch, 2005). Addressing

this, there are also some examples of emerging unique and innovative programmes.

However, on the whole, the field is lacking in diversity of approach. Research into a

broader range of therapies, including interventions specifically targeted at adolescent

66

males (particularly “at-risk” individuals) would be helpful. Future studies should also

aim for greater methodological rigour including long-term follow-up, a range of

outcome measures, and more studies conducted within the UK. This is essential for

drawing any substantial conclusions about the effectiveness of these interventions

going forward. In addition, researchers should consider following the example of

Herrmann and McWhirter (2003) and involve young people in the design of

intervention programmes, to ensure that therapies appeal to modern youth; whether

this be via inclusion of technology or creative techniques requires further

consideration and discussion with the client group. Given the current prevalence of

conduct disorders in boys, there is still much need and scope for new, innovative,

targeted interventions for adolescent boys with anger difficulties.

67

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81

Research Part 2 – Empirical Paper

Title: Taking ACTion on Anger: A feasibility study investigating

the effectiveness and acceptability of an ACT-based anger intervention for

adolescent males in a school-context.

Word count 9998 (excluding abstract, tables, figures, references, and

appendices)

82

Abstract

Introduction: Conduct disorder (and associated anger and aggression) is

prevalent amongst UK adolescent males, and can result in significant individual and

societal consequences. Interventions to support this client group are therefore vitally

important. Current evidence supports a cognitive behavioural therapy (CBT)

approach to managing anger, however few alternatives are available, and existing

interventions are not targeted specifically at males. This study aimed to address this

by drawing on the growing research interest in ‘third-wave’ therapies. The purpose

of this study was to evaluate the acceptability, feasibility, and preliminary

effectiveness of a short-term ACT-based group anger intervention for adolescent

males.

Method: A mixed-method pre-post design was employed. Participants were

year 8 and 9 adolescent males with mild-moderate anger difficulties, recruited from a

school setting. The 5-week intervention, entitled “Taking ACTion on Anger”, was

delivered in school. The Strengths and Difficulties Questionnaire (SDQ), Adolescent

Anger Rating Scale (AARS), and the Mindful Attention Awareness Scale-

Adolescent (MAAS-A) were collected at pre-group, post-group and at 3-month

follow-up. A focus group was also completed at post-group and analysed via

Inductive Thematic Analysis.

Results: Of the 17 participants who began the intervention, 15 completed.

The intervention was acceptable to the boys, and relatively feasible to run in a

school. Repeated measures analysis of variance (ANOVA) comparisons between the

three time points were largely non-significant. Positive changes were suggested by

the effect sizes and the qualitative analysis. Questionnaires were largely unacceptable

to the boys and raised issues of reliability.

83

Conclusion: Preliminary support was found for the acceptability and

feasibility (with some modifications) of “Taking ACTion on Anger”. Effectiveness

of the intervention was supported in the qualitative data, but requires further

quantitative verification. Future research should consider different outcome

measures, a larger sample, and the use of a control group to achieve power and

evaluate cause-effect relationships.

Key words: adolescent, anger, aggression, intervention, boy, ACT, acceptance and

commitment therapy

84

Introduction

A recent UK survey of 48 Child and Adolescent Mental Health Services

(CAMHS) reported that 276,468 children and young people were referred to these

services over the course of a year. 41% of these referrals were for males, with the

majority being over 11 years old (Children’s Commissioner for England, 2016).

National figures suggest that 1 in 10 children suffer from a mental health problem,

with conduct disorders being the most common, experienced by 5.8% of all children,

6.6% of adolescents, and 8.1% of adolescent males (compared to 5.1% of adolescent

females) (Office for National Statistics, 2005). Conduct disorder includes displays of

aggression (American Psychiatric Association, 2013); given the link between anger

and aggression, it is reasonable to assume that many of these boys have difficulties

with managing anger. Furthermore, research in America highlights that the

“diagnostic” picture may significantly underrepresent the prevalence of anger-related

issues (see McLaughlin et al., 2012). Parsonage, Khan and Saunders (2014) suggest

that a child with conduct problems can carry an economic cost of approximately

£260,000. Effective interventions addressing the difficulties that these young men

experience is therefore important at an individual and societal level.

There currently exists a good evidence base for CBT-based interventions for

anger (see Beck & Fernandez, 1998), and specifically for anger in children and

adolescents (see Sukhodolsky, Kassinove, & Gorman, 2004). Interventions based on

social cognitive-behavioural problem-solving approaches are recommended in

current National Institute for Clinical Excellence (NICE) (2013) guidelines for

children and young people with antisocial behaviour and conduct problems. However

CBT approaches are not for everyone; a recent literature review of anger

interventions for adolescent males (Livings, John, & Morison, unpublished thesis)

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highlighted that whilst some research has continued to support the

social/cognitive/CBT framework (e.g. Down, Willner, Watts & Griffiths, 2011;

Humphrey & Brooks, 2006), effective results from this approach are not guaranteed

(e.g. Puksar, Grabiak, Bernardo & Ren, 2009). Furthermore, today’s adolescents are

very different to those researched at the peak of interest in this field (c. 1990s). One

of the most notable differences is the increased availability of the internet and social

media, with 92% of American teenagers reportedly going online every day (Pew

Research Centre, 2015), potentially leaving little space for ‘down-time’ or reflection.

This lack of ‘head space’ may be relevant to consider when designing interventions

relevant for ‘Generation Z’ (see Strauss & Howe, 1991), as for some of these young

people it may be helpful to learn ways of ‘getting out’ of their preoccupied minds,

rather than (or in addition to) learning to ‘challenge unhelpful thinking’.

Multi-Systemic Therapy (MST) has also produced positive outcomes for

clients with complex difficulties (e.g. Weiss et al., 2013) and is recommended by

NICE (2013) for young people aged 11-17 with conduct disorders. However MST

requires a full-time therapist being available to see a family 24/7 (Fonagy, Target,

Cottrell, Phillips, & Kurtz, 2005). Given the current financial constraints on the UK

public sector services, interventions with lower costs are desirable.

In addition to the difficulties mentioned with CBT and MST, Livings, John

and Morison (unpublished thesis) highlighted a lack of diversity of interventions,

limited interventions targeting males, and a lack of UK-based studies. Whilst there is

clearly a valid place for CBT and MST, there has more recently been a movement in

research towards ‘third-wave’ therapies9. In particular, mindfulness and ACT-based

approaches may be relevant for this client group for several reasons.

9 As of December 2016, 171 RCTs of ACT had been published (see Hayes, 2016).

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Firstly, their theoretical underpinnings fit well with the concept of anger.

ACT is a transtheoretical model based around 6 core constructs. Each of these core

constructs may be helpful for dealing with problem anger and aggression in the

following ways; 1) Contact with the present moment – aimed at focusing attention on

the here-and-now, rather than in the past or future (e.g. ruminating or plotting

revenge); 2) Acceptance – learning to sit with difficult thoughts and feelings (such as

anger) rather than having to do something with them (such as lashing out); 3)

Cognitive defusion – creating separation from powerful thoughts (e.g. “he’s taking

me for a mug!”), and noticing these simply as thoughts, as opposed to something that

one has to action; 4) Self-as-context – becoming in touch with the part of oneself that

is the container of thoughts, feelings, memories, etc, and noticing them pass by,

rather than being caught up in these experiences; 5) Values – re-connecting with

what is important to you (e.g. being caring, rather than being aggressive), and 6)

Committed action – taking action in line with your values, rather than action that

may steer you away from them (see Harris, 2009). Eifert and Forsyth (2011) have

explored an ACT approach to managing anger, publishing a self-help book on this

(Eifert, McKay, & Forsyth, 2006). Roberton, Daffern and Bucks (2012) described

the difficulties with under-regulation of anger (e.g. acting out anger) and over-

regulation (e.g. suppression), and posit that emotional acceptance, awareness and

flexible emotional regulation strategies may be helpfully integrated into

interventions, making specific reference to mindfulness and acceptance based

approaches. Wright et al. (2009) described how mindfulness and acceptance could be

helpful for anger, via observation of one’s experiences improving tolerance of them,

breaking ruminative cycles, and improving self-awareness leading to more conscious

choices about behaviours. Denson (2015) also discussed the mechanisms by which

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mindfulness and other strategies may help with reactive anger (see figure 1),

highlighting the link between mindfulness and possible improved executive

functioning (see Chiesa, Calati & Serretti [2011] for a review of this literature).

Mindfulness-based interventions for anger may therefore have wider implications

than simply reducing reactive aggression.

Figure 1. Theoretical impact of interventions for reactive anger (Denson,

2015)

Secondly, third-wave interventions are generating significant evidence to

support their effectiveness across a range of populations and presentations. Weare’s

(2012) review of mindfulness based interventions with children and adolescents

reported its beneficial effects on a wide range of variables, including wellbeing,

depression, attention, anxiety, and behavioural problems, and are well-tolerated by

young people (Burke, 2010; Huppert & Johnson, 2010). Similarly, ACT has been

researched as a therapeutic intervention for depression, pain, stress, anxiety, and

psychosis, with results showing tentative support for its effectiveness (see Öst, 2014;

Powers, Zum Vorde Sive Vording, & Emmelkamp, 2009; and Ruiz, 2012). However

ACT research on adolescents is still very much in its infancy. In their 2011 review,

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Murrell and Scherbarth found only four published studies of ACT with adolescents.

More recently, Livheim et al. (2015) conducted a “transdiagnostic test” of ACT with

adolescents, by piloting an intervention with Australian adolescents with depression,

and Swedish adolescents experiencing stress. Australian participants showed

significant improvements in depressive symptoms (d=0.86) and decreases in

psychological inflexibility (d=0.73). In the Swedish sample, measures of stress

improved significantly in the ACT group (d=1.2). The transdiagnostic support

currently being generated for third-wave therapies suggests that they have the

potential to be helpful for anger too.

Further potential benefits of third-wave therapies to this client group include

the fact that mindfulness and its focus on ‘being present’ may be a helpful antidote to

the stress of the twenty-first century communication age, and the preoccupied mind

that this may generate. The interventions can also be delivered in group10 formats,

and may therefore be cost-effective.

In light of the above, the aim of this study was to design, deliver, and

evaluate the feasibility, acceptability, and preliminary effectiveness of a novel ACT-

based anger intervention for adolescent males. As there is a clear need for low-cost,

preventative approaches, the proposed intervention – entitled “Taking ACTion on

Anger” - was a short-term (5-week) skills-based intervention that could be delivered

in groups in school to boys with mild-moderate anger difficulties.

The research aimed to address the following questions:

1. How acceptable is an ACT-based intervention to adolescent males with

anger difficulties?

10 MBSR and MBCT are both group programmes, and ACT has previously been delivered in group format (e.g. Livheim et al., 2015).

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2. How acceptable are the measures used?

3. Following intervention, were there any changes observed in the

adolescents on anger, wellbeing, and ACT variables?

3a. Were there any changes on measures of instrumental anger,

reactive anger, anger control, and total anger, as measured by the

Adolescent Anger Rating Scale?

3b. Were there any changes in general wellbeing, as measured by the

Strengths and Difficulties Questionnaire?

3c. Were there any changes in levels of mindfulness, as measured by

the Mindful Attention Awareness Scale – Adolescent version?

3d. Were there any changes in levels of distress tolerance, as

measured by the Computerised Mirror Tracing Persistence Task?

3e. Were there any changes in value-guided living, as measured by the

Valued Living Questionnaire?

4. How feasible is it to provide an ACT intervention within the school

context?

Method

Study design

The study follows a within-participants mixed-methods quasi-experimental

design. Participants were compared against themselves at pre-treatment, post-

treatment and 3-month follow-up. The study follows a “Triangulation: Convergence”

model (Cresswell & Clark, 2011) whereby quantitative and qualitative data are

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collected concurrently and given equal weight, analysed separately, and merged at

the interpretation stage. To lessen the possibility of bias, qualitative data was

analysed first.

The study formed part of a parallel research project. Both researchers

contributed equally to the design and facilitation of the intervention. The projects

were separated at the data analysis stage; the author of this research project analysed

data gathered from the adolescents, whilst the parallel-researcher analysed data

gathered from the school and teachers.

Participants

School demographics: Participants were recruited from year 8 and 9 male

students attending a secondary school in inner-city London, UK. The school is in the

top 30% most deprived neighbourhoods of the country. Recent school OFSTED

reports indicate that nearly three-quarters of students are eligible for support through

the pupil premium fund11 and there are a higher number of minority ethnic

backgrounds than most schools of similar size. There are slightly more male than

female students, and almost 40% of students do not have English as their first

language.

Recruitment process. Senior Leadership Team (SLT) members were

provided with the inclusion criteria for the pupils’ participation (see table 1) and

subsequently selected students for inclusion. SLT members were advised that the

intervention was targeted at students who would typically be presenting with

persistent disruptive behaviour in class connected to anger and aggression, but that

their difficulties were not so severe that they were (for example) having regular

contact with the criminal justice system. The researchers thus relied largely on

11 The pupil premium fund is allocated to students who are either looked after children or eligible for free-school meals.

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teacher assessment of “mild-moderate” anger difficulties, guided by the above

information and inclusion / exclusion criteria. Students and parents were contacted

by the research team to discuss participation and gain consent from both parties.

Table 1

Inclusion and Exclusion Criteria

Inclusion criteria Exclusion criteria

Displaying a moderate level of difficulty managing anger/aggression.Communicates in English.Attends school regularly.

Receiving psychological intervention elsewhere.

Severe and enduring mental health difficulties.

Identified as high risk of harm to self or others, e.g. expressing suicidal ideation, or extensively involved with the criminal justice service.

Not in mainstream schooling (e.g. internally excluded).

Unable to speak or read English.

Neurodevelopmental disorders including autism.

Final sample. Sample size was limited by the practical constraints of the

school and the feasibility nature of the study. It was agreed with the school that three

groups containing 5-7 students would run, providing a total sample of 15-21

participants. For the quantitative outcome measures, using repeated measures

ANOVA analysis at three time points, this is sufficient for detection of large effects

(partial η2=0.14; power=0.80, α=0.05, required sample=12).12 18 individuals were

subsequently invited to participate in the intervention, 17 of which consented and

commenced the programme, and 15 completed the programme13. 14 participants

provided the complete data set, all of which were in year 9 (2 of the 3 who failed to 12 Using the same power and α, to detect a medium effect (partial η2 =0.06) would require a sample of 28, and to detect a small effect (partial η2 =0.02) a sample of 82. 13 See attendance / attrition section in results section for further information.

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provide the full data set were in year 8), and were aged 13-14 (mean=13.77). School

records indicated 10 of the participants were “Black or Black British”, two were

“White”, and two were “Mixed or Dual background”. 14 of the 15 programme

completers participated in the focus groups. The remaining participant in group one

was interviewed separately as he was not in school on the day of the scheduled focus

group; his data was transcribed and analysed in the same manner as the focus group

data.

Measures

Quantitative measures – Self report. A range of questionnaires were

selected to assess change between the three time points (see table 2 / appendix 2 for

full details).

Adolescent Anger Rating Scale (AARS) (Burney, 2001). The AARS is a 41-

item self-report anger scale, with responses scored on a Likert scale ranging from 1-

4. Participants are asked to rate how often they have experienced a series of

situations when angry, e.g. “have difficulty controlling my temper”. Response

options range from “hardly ever” to “very often”. The AARS consists of three

subscales: ‘Instrumental Anger’ (IA), ‘Reactive Anger’ (RA), and ‘Anger Control’

(AC), which can be combined14 to give a Total Anger score. Higher scores (lower for

AC) indicate greater difficulties with anger. Burney (2001) reports high internal

consistency, ranging from α=0.81-0.92 across scales15.

Strengths and Difficulties questionnaire (Youth report version) (SDQ)

(Goodman, 2001). The SDQ is a 25-item self-report measure of overall wellbeing in

children and adolescents. Respondents are presented with a series of statements

14 See manual (Burney, 2001) for details of how scales are combined. 15 Using the norms provided, it is impossible to score below “average” for IA, and below “moderately low” for RA and AC for the comparison group used for this study (boys grades 6-8).

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about their wellbeing, e.g. “I get very angry and often lose my temper”, and provide

answers on a 3-point Likert scale, ranging from “not true” to “certainly true”. In an

initial pilot study of UK 11-16 year olds (Goodman et al., 1998), internal consistency

was generally good although varied across its five subscales (α=0.61-0.82). The five

subscales include: emotional symptoms (α=0.75), conduct problems (α=0.72),

hyperactivity-inattention (α=0.69), peer relationship problems (α=0.61), and a

prosocial scale (α=0.65). The first four subscales are combined to create an overall

‘total difficulties’ score (α=0.82). In addition, the hyperactivity-inattention and

conduct subscales are combined to create an ‘externalising difficulties’ score, whilst

the emotional symptoms and peer relationship problems subscales are combined to

create an ‘internalising difficulties’ score. Higher scores (lower for prosocial scale)

are indicative of greater difficulties. The scores are classified, ranging from “close to

average” to “very high” (or “very low” for prosocial scale) (see appendix 3). These

categories are developed from a UK sample (see

http://sdqinfo.org/py/sdqinfo/c0.py16).

The Mindful Attention Awareness Scale – Adolescent version (MAAS-A)

(Brown, West, Loverich & Biegel, 2011). The MAAS-A is a 14-item questionnaire

assessing levels of mindfulness. Participants complete answers on a 6-point scale,

ranging from “almost always” to “almost never”, which are then averaged to give a

mean mindfulness score (range=1-6). An example includes “I find myself doing

things without paying attention”. In their sample of 14-18 year olds, Brown et al.

(2011) reported high internal consistency (α=0.82 and 0.84).

Valued Living Questionnaire (VLQ) (Wilson, Sandoz, Kitchens & Roberts,

2010). The VLQ assesses the ACT concept of “values”. It contains 10 valued living

16 A peer-reviewed publication does not exist for these norms. Personal communication with the author of the SDQ (Goodman) advised referencing the “youth in mind” website for this data.

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domains (e.g. family relations, education/training, recreation) and participants are

asked to rate on a 1-10 scale a) how important each of these domains are to them,

with 1 being “not at all important” and 10 being “extremely important” and b) how

consistently they have lived by them over the past week, with 1 being “not at all

consistent with my value”, and 10 being “completely consistent with my value”.

Internal consistency varied across the authors’ two studies (α=0.58-0.83; second

study α=0.75-0.77).

Quantitative measures – Behavioural.

The computer-based Mirror Tracing Persistence Task (MTPT) (Strong et

al., 2003). The MTPT was selected as a measure for distress tolerance, which

requires participants to trace the outline of an object with the cursor on a computer

programme, whilst the cursor is programmed in reverse, i.e. when moving the mouse

left, the cursor moves right. When a participant takes too long to move the cursor, or

makes errors, a loud error sound is made and the participant must start again.

Frustration tolerance is measured via time elapsed before participants quit the task.

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Table 2

Details of Measures

Authors Measure Age group Description of measure Details of scales Psychometric properties

Burney (2001)

Adolescent Anger Rating Scale (AARS)

11-19 year olds

41 item self-report scale measuring instrumental anger, which measures the “rate and intensity of delayed angry responses that result in a desired and planned goal of revenge and/or retaliation”; reactive anger, measuring the “rate and intensity of angry responses that are immediately expressed when an event is perceived as negative, threatening, or fearful”; and anger control, measuring “an adolescent’s propensity to proactively resolve instrumental and/or reactive responses to anger”. Questions are measured on a 4 point Likert scale. Higher scores = greater difficulties managing anger.Norms were developed from

Instrumental scale range = 20-80Reactive scale range = 8-32Anger Control scale range = 13-52Total Anger = 41-164

Cronbach’s alpha for boys grades 6-8:Instrumental = 0.92; Reactive = 0.81; Anger control = 0.84 Total scale = 0.92

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a sample of 4,187 adolescents in the USA.

Goodman (2001)

Strengths and Difficulties Questionnaire (Self-Report) (SDQ-SR)

11-17 years 25 item self-report questionnaire, 3 point Likert scale. Scale covers: 1. emotional symptoms, 2. conduct problems, 3. hyperactivity/inattention, 4. peer relationship problems, 5. prosocial behaviour.Higher scores = greater difficulties (excluding prosocial scale where higher scores = higher prosocial behaviour).Sum of scales 1-4= total difficulties score Sum of 1 and 4 = internalising difficultiesSum of 2 and 3 = externalising difficulties

Scales 1 – 5 range = 0-10Internalising range = 0-20Externalising range = 0-20Total difficulties range = 0-40

Pilot study (Goodman, Meltzer & Bailey, 1998) Cronbach’s alpha in a sample of 11-16 year olds:Total difficulties: 0.82Emotional symptoms: 0.75Conduct problems: 0.72Hyperactivity: 0.69Prosocial behaviour: 0.65Peer problems: 0.61

Retest stability. Total difficulties: 0.62Emotional symptoms: 0.57Conduct problems: 0.51Hyperactivity: 0.60Prosocial behaviour: 0.51Peer problems: 0.54

Brown, West, Loverich and Biegel (2011)

Mindful Attention Awareness Scale – Adolescent (MAAS-A)

14-18 years 14 item, 6 point Likert self-report scale assessing mindfulness, defined as “a receptive state of mind in which attention, informed by a sensitive awareness of what

Mean scores can range from 1-6.

Cronbach’s alpha = 0.82 and 0.84

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is occurring in the present, simply observes what is taking place” (pp. 1024). Higher scores = higher levels of mindfulness. Participants are given a mean score over the 14 items (range = 1-6).

Wilson, Sandoz, Kitchens & Roberts (2010)

Valued Living Questionnaire (VLQ)

No specific age clearly recommended but piloted on undergraduates.

Originally used as therapeutic tool within act. 10 different valued domains. Each of the 10 valued domains are rated on Likert scales ranging from 1-10.Participants rate a) how important each of these are to them, and b) how consistently they have been living their life by them over the past week. The two scores are then combined to create a composite score; a measure of how much an individual has been living life by values that are important to them.

Importance score = sum of 10 valued domains. Range = 10 -100. Consistency score = sum of 10 valued domains. Range = 10 -100.Composite score = “the product of the Consistency and Importance ratings […] calculated for each domain represented in thequestionnaire. The mean of these products is the valued living composite.” (p. 257).

Cronbach’s alpha:Ranged from 0.58 to 0.83 in first study but better in second study (0.75 to 0.77).

Test retest reliability:Importance scale: Overall = 0.9. Individual items ranged from 0.61 to 0.82.

Consistency Scale: Overall = 0.58. Individual items ranged from 0.43 to 0.61.

Composite score: Overall = 0.75. Individual items ranged from 0.57 to 0.79.

Strong, Lejuez,

Computerised Mirror Tracing

Unclear what age range

Distress tolerance task whereby participants trace the

n/a n/a

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Daughters, Marinello, Kahler & Brown (2003)

Persistence Task

originally designed for (likely adults given its basis in addictions research), however has since been used in research with adolescents aged 10-14 (Seymour, Macatee & Chronis-Tuscano, 2016)

outline of a shape on a computer screen. The cursor moves in the opposite direction. A buzzer sounds and the cursor returns to the start if the participant moves the cursor outside of the shape outline or pauses for more than two seconds. Participants can end the task by pressing a certain key. Distress tolerance is measured by time taken to terminate task.

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Qualitative measures. A semi-structured exploratory focus group was

completed with the participants at post-group. The focus group interview questions

were designed by the research team (see appendix 4).

Process notes / informal measures. Facilitators completed unstructured

interviews of one another after each group and recorded informal journal-style

process and content notes on each session delivered (see example in appendix 5). A

briefer focus group was also completed with the participants at 3-month follow-up

(appendix 6). This data was not subject to formal analysis; however the 3-month

participant data was transcribed and reviewed at a more surface level to establish

what the participants had remembered, and if any further reflections had arisen since

the end of the group that may confirm or contradict the themes that arose from the

post-group focus groups.

Procedure

Process of developing intervention. The intervention was designed by the

author and the parallel researcher. The development of the intervention was overseen

by the research supervisor, an experienced CAMHS clinical psychologist. External

consultation was also sought on the protocol from an experienced clinical

psychologist with extensive practise of delivering and supervising individual and

group-based ACT interventions. Consultation on the appropriateness and

acceptability of the content to an adolescent audience was sought via a focus group

with an opportunity sample of adolescent males. The protocol was modified

accordingly following all stages of consultation.

The protocol drew on existing ACT literature, including “ACT on life, not on

anger” (Eifert et al., 2006), and “Get out of your mind and into your life for teens”

(Ciarrochi, Hayes, & Bailey, 2012). The sessions were structured around the

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“hexaflex” ACT model, with each activity aimed at developing one or more of the

six core ACT constructs.

To ensure the content was engaging and relevant, there was an emphasis on

interactive exercises, metaphors, adapted mindfulness exercises (e.g. mindfulness of

music), popular culture, and role models. An accompanying workbook provided key

points from each session, with space to complete exercises and homework activities.

The workbook also aided manualisation of the intervention and promoted treatment

fidelity.

Intervention delivery. The intervention and focus groups were delivered by

the author and the parallel researcher. A school-based facilitator also attended each

session to ensure that school policies were adhered to. The programme ran for five

weeks, with each session lasting for one hour, with additional time in the final

session for completing measures and the focus group. A preliminary session involved

discussing information sheets, gaining consent to participate from the young people,

and completing pre-group questionnaires. The school-based facilitator was assigned

to facilitate a weekly mindfulness practice between scheduled sessions17. A summary

of the session structure can be seen in table 3, and full details of the protocol can be

found in appendix 7.

Table 3

Summary of Programme Structure

Session Content

17 Due to school staff issues, the school-based facilitator changed between group 1 and group 2. The same individual facilitated groups 2 and 3.

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Preliminary session Information sheets, consent forms, pre-group measures

Session 1 – Chilling with your tiger: For warriors, not zombies

Introducing key metaphors – Mindless Zombie, Wise Warrior, and Anger TigerIntroducing Defusion, Committed Action, Acceptance, and Mindfulness

Session 2 – Pursuing your values with courage and strength

Dropping the struggle with experiential avoidance via embracing acceptanceValues – what do you want people to say about you at your 18th birthday party?Role models activity – LeBron James

Session 3 – The “Anger Mask”

Video clips and discussions around what emotions anger masks – link to Acceptance and Choice PointIntroduced Self-As-Context - sky and weather metaphorDefusion – using “silly” accents

Session 4 – Dropping the struggle

The illusion of control – idea of not having control over one’s feelings (“Fall in Love with the Spot on the Floor”) but having control over actions via practicing acceptance (“Urge Surfing”)

Session 5 – Becoming a wise warrior for good

Review of metaphors, key concepts, and key activities Action planning and goal settingCertificates of achievementPost-group measures including focus group

Analytic strategy. Both quantitative and qualitative data were used to

address the four research questions.

Quantitative analysis. Attendance data was used as a proxy-measure of

acceptability of the group. Acceptability of the measures were explored via looking

at completion rates, floor and ceiling effects, and calculation of Cronbach’s alpha.

Repeated measures ANOVAs were used to explore differences between the three

time points on the questionnaire data. In addition, effect sizes (Cohen’s d) were

calculated for pre-post and pre-follow-up comparisons. Given the small sample,

small N analysis was undertaken; reliable and clinical change calculations were

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computed for each of the participants using the Leeds Reliable Change Calculator

(Morley & Dowzer, 2014). Feasibility was assessed via attendance data.

Qualitative analysis. Focus group data was used for each of the research

questions. The three focus groups were subject to inductive thematic analysis,

following Braun and Clarke’s (2006) suggested approach. The author adopted a

critical realist perspective, focusing largely on manifest content. Given the feasibility

nature of the research, and the relatively few existing studies on ACT with

adolescents or ACT with anger, it was felt that a data-driven rather than theory

driven approach would be appropriate. The mixed-methods approach was more

aligned to a critical-realist perspective than a social constructionist perspective,

hence the focus on manifest content. However, the author was alert for any notable

exceptions in which the participants’ words may have had more than one meaning;

for example, if their words contradicted their non-verbal cues, or if it was very

apparent that their intended message was different from their spoken words.

Recordings of each focus group were listened to several times and transcribed

by the researcher. Each transcript was read and re-read to gain initial familiarity with

the data and generate ideas for codes. Each transcript was then coded, and re-coded

when overlap was observed between codes. Consultation with the supervisor

occurred to ensure initial codes had appropriate face validity and sufficient depth of

analysis, and to discuss initial theme generation. The above process was then

repeated for the individual interview that occurred with one participant in group one

who was absent from the focus group. No new codes emerged for this interview.

Codes were then organised into initial themes, and transcripts were again reviewed

and recoded when necessary. Movement back and forth between codes and themes

occurred until final themes were generated that were sufficiently coherent and

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explained the majority of data. Finally, appropriate extracts were selected to

represent the predominant themes that emerged. All participants were given

pseudonyms to protect anonymity. An audit trail of this process and examples of

coded extracts can be seen in appendix 8.

A summary of how the data was analysed in relation to the research questions

is displayed in table 4.

Table 4

Analytic Strategy

Research question Quantitative analysis Qualitative analysis

How acceptable is an ACT-based intervention to adolescent males with anger difficulties?

Attendance Focus groups

How acceptable are the measures used?

Missing data / whether measures were completed or notFloor and ceiling effectsCronbach’s alpha

Focus groups

Following intervention, were there any changes observed in the adolescents on anger and ACT variables?

ANOVAEffect sizesSmall N analysis

Focus groups

How feasible is it to provide an ACT intervention within the school context?

Attendance Focus groupTreatment fidelity

Ethical approval. Ethical approval was acquired from the Faculty of Arts

and Human Sciences at the University of Surrey (see appendix 9). Given the age of

the participants, both the individuals taking part and their parents provided informed

consent for the young people to participate in the research (see appendix 10).

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Students and parents were provided with a written information sheet. Consent from

parents was then obtained verbally through discussion with the researcher or member

of school staff over the telephone. Participants signed consent forms in the

preliminary session. Participant data was stored confidentially on an encrypted USB

stick. All data in the report was anonymised and pseudonyms were employed to

protect participants’ confidentiality. Participants were offered the right to withdraw

from the study at any point, and the right to withdraw their data up until the end of

their intervention, after which time data would be analysed and written up.

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Results

Information on data normality will first be presented. Quantitative data will

then follow, and will be structured in relation to each research question. Finally,

overall qualitative data will be presented. The integration of quantitative and

qualitative data under the main research questions will occur in the discussion.

Assessing normality

Normality of distribution was considered by examining skewness and

kurtosis, performing Kolmogorov-Smirnov tests, and visual inspection of histograms,

plots and box plots (see appendix 11). There was some indication of non-normality

of some of the data at some time points. However, as the majority of variables

approximated a normal distribution at the majority of time points, and given that

ANOVA is considered robust to violations in assumptions (e.g. see Norman, 2010),

it was decided to proceed with parametric analyses.

How acceptable is an ACT-based intervention to adolescent males with anger

difficulties?

Attendance/Attrition. Attendance rates are summarised in figure 2. Overall

attendance for the three groups was high at 89%. Of the 17 participants who began

the groups, two failed to complete; one in group two withdrew, and one in group

three moved to another school. One further participant (group two) completed the

group but failed to provide follow-up data as he was excluded from school, leaving a

total of 15 participants (88%) who completed the group and provided post-group

data, and 14 who provided follow-up data (82%).

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Session

1

Session

2

Session

3

Session

4

Session

5

Total p

rogram

me atte

ndan

ce0

20

40

60

80

100

Group 1 (n=7) Group 2 (n=5) Group 3 (n=5) Overall (n=17)

Figure 2. Attendance rates (%)

How acceptable are the measures used?

Missing data / Completion of measures. One participant completed the

incorrect version of the SDQ at post-test; his responses on this were thus omitted

from analysis. Across all completed measures, 10 data points were missing,

amounting to 0.28% of the total recorded data. Guidelines for pro-rating the SDQ

(see http://sdqinfo.org/py/sdqinfo/c0.py) and AARS (see Burney, 2001) were

followed. As the MAAS-A provides a “mean” as its overall score, for the two

occasions a data point was missing on this measure, a mean of 13 questions was

used, rather than 14.

VLQ. The participants did not like completing the VLQ, and regularly failed

to complete it fully or to give due care when completing it by, for example, circling

the same number for everything. The VLQ data was thus excluded from analysis.

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MTPT. Due to logistical difficulties with computer access, only three

students attempted the MTPT at pre-treatment only. It was therefore not included in

quantitative analyses, although participant comments on the task were retained in

qualitative data.

AARS, MAAS-A, SDQ. 100% of the 14 participants who finished the group

completed these measures at pre, post and follow-up. One participant completed the

incorrect version of the SDQ at follow-up, and so was excluded from analysis.

Floor and ceiling effects. The number of participants falling above clinical

cut-offs (see appendix 3 for details) are displayed in table 518. Notable floor effects

were present, as 60-100% of participants (across the three time points) scored in the

non-clinical range. This suggests that for this cohort of adolescents, the AARS in

particular, as well as the SDQ, were not detecting the boys’ difficulties, and are

perhaps aimed at a higher risk and/or different client group.

Table 5

No. of participants reaching clinical thresholds at each time point

No. above clinical threshold at pre- (n=15)

No. above clinical threshold at post- (n=15)

No. above clinical threshold at follow-up (n=13 for SDQ; n=14 for other measures)

AARS instrumental 3 0 0AARS reactive 3 4 3AARS control 0 0 1AARS total 4 0 0SDQ conduct 6 5 4SDQ hyperactivity 5 4 4MAAS-A n/a n/a n/a

18 Data included only on most applicable variables, rather than all SDQ subscales.

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Cronbach’s α. Alphas were calculated for all scales, excluding the AARS

total anger scale19, and can be seen in table 6. Additional reliability analyses can be

found in appendix 12. Alphas were particularly low and/or inconsistent for all SDQ

scales, excluding SDQ prosocial. Considerable caution should therefore be employed

when interpreting outcomes from these scales.

Table 6

Cronbach’s alphas

Scale No. of items in scale

Pre-group alpha (n=17)

Post-group alpha (n=15)

Follow-up alpha (n=13)

AARS control 13 0.804 0.675 0.498 AARS instrumental 18 0.924 0.794 0.798 AARS reactive 8 0.831 0.741 0.765b

MAAS-A 14 0.628a 0.697b 0.848b

SDQ prosocial 5 0.624 0.567 0.634 SDQ hyperactivity 5 -0.276 0.395b 0.797 SDQ emotional 5 0.347a 0.664b 0.373d

SDQ conduct 5 0.446 0.355 0.761 SDQ peer 5 0.015 0.807 0.161e

SDQ total 20 0.397a 0.772c 0.644e

NB: N (no. of participants) varies due to missing data and declining number of students at each time pointa. n=16; b. n=14; c. n=13; d. n=12; e. n=11

Following intervention, were there any changes observed in the adolescents on

anger and ACT variables?

Inferential statistics. Data from the three groups were combined and

analysed via repeated-measures ANOVAs. A Bonferroni correction was applied to

all post-hoc comparisons. Descriptive data, ANOVA outcomes, and effect sizes are

presented in table 7. There was a significant difference in anger control

(F(2,26)=4.18, p<.05), with pairwise comparisons revealing a significant decline

between post-test and follow-up (p<.05, d=0.76). No other differences were

statistically significant.

19 This was not calculated as the AARS total anger score is calculated using a specific formula, as opposed to simply summing subscales.

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Table 7

Descriptive data, ANOVA outcomes, and effect sizes for all quantitative variables (to 2 d.p)

Measurea Range obtained

Pre (mean, SD)

Post (mean, SD)

Follow-up (mean, SD)

ANOVA – main outcome

Pre - Post Pre - Follow up

F

(2,24)c

P value

Effect size (d)

Desired effect?b

Effect size (d)

Desired effect?b

AARS inst. 21-49 28.29 (10.25) 25.50 (4.90) 24.50 (3.94) 3.09 0.08 0.37† Yes 0.53†† YesAARS reac. 10-32 18.86 (5.87) 17.50 (4.43) 17.43 (5.10) 0.66 0.53 0.26† Yes 0.26† YesAARS cont. 23-48 33.21 (7.43) 33.36 (6.13) 29.43 (4.15) 4.18 0.03 -0.02  - 0.65ꜞꜞ NoAARS total 53-120 78.93 (20.26) 74.64 (11.42) 77.50 (11.36) 0.82 0.47 0.27† Yes 0.09  -SDQ emot. 0-5 1.56 (1.12) 2.19 (1.91) 1.90 (1.58) 1.56 0.25 -0.42ꜞ No -0.26ꜞ NoSDQ cond. 2-7 3.54 (1.90) 3.38 (1.80) 2.92 (2.29) 0.94 0.40 0.08 - 0.29† YesSDQ hyp. 3-7 4.23 (1.17) 4.19 (1.80) 4.69 (2.39) 0.46 0.64 0.03 - -0.26ꜞ NoSDQ peer 0-5 2.00 (1.35) 2.08 (2.53) 2.27 (1.64) 0.08 0.93 -0.04 - -0.18 -SDQ int. 1-8 3.56 (1.81) 4.27 (4.04) 4.17 (1.97) 0.64 0.54 -0.24ꜞ No -0.33ꜞ NoSDQ ext. 5-13 7.77 (2.52) 7.58 (3.12) 7.62 (4.25) 0.03 0.97 0.07  - 0.05 - SDQ total 6-17 11.33 (3.44) 11.85 (6.46) 11.79 (5.09) 0.08 0.93 -0.10  - -0.11  -SDQ pro. 3-10 6.31 (2.36) 6.23 (1.88) 6.15 (1.91) 0.04 0.96 0.04 - 0.07 -MAAS-A 3.43-5.64 4.05 (0.64) 4.09 (0.77) 4.30 (0.83) 0.75 0.48 -0.06  - -0.33† Yes

a. Full names or measures are: AARS instrumental anger, AARS reactive anger, AARS anger control, AARS total anger, SDQ emotional problems, SDQ conduct problems, SDQ hyperactivity-inattention, SDQ peer relationship problems, SDQ internalising, SDQ externalising, SDQ total difficulties, SDQ prosocial behaviour, MAAS-A.b. Reported if d ≥ 0.2 (i.e. minimum small effect size)c. Degrees of freedom varied according to N and whether sphericity was violated. F (2, 24) correct for SDQ conduct, hyperactivity, peer, externalising, total and prosocial. F (2,26) correct for AARS reactive, anger control, and MAAS-A. F (2,12) correct for AARS instrumental and AARS total, F (2,11) correct for SDQ emotional and internalising.† Non-significant small effect in desired direction. †† Non-significant medium effect in desired direction Significant at p<.05 levelꜞꜞ Non-significant medium effect in undesired directionꜞ Non-significant small effect in undesired direction

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Effect sizes. With the exceptions of anger control, SDQ hyperactivity-

inattention, and SDQ externalising, the most pertinent measures (instrumental anger,

reactive anger, total anger, SDQ conduct, and MAAS-A) moved in the desired

direction, whilst less directly relevant measures moved in the undesired direction

(SDQ emotional and SDQ internalising), or displayed little change (SDQ peer

relationship problems, SDQ prosocial, and SDQ total difficulties).

Small N analysis. Reliable and clinically significant change scores were

calculated for the AARS, MAAS-A, SDQ conduct and SDQ hyperactivity-

inattention, as these were thought to be most relevant to the study. ‘Criterion A’20

was used to set the level for clinically significant change as the descriptive data for

the participants in the study appeared similar to (or ‘better’ than) the ‘normative

samples’ available for comparison. They were therefore compared to themselves as

the clinical population.

As seen in table 8, the majority of participants did not demonstrate reliable

change, a moderately-sized minority showed reliable improvement on some

measures, whilst a much smaller minority declined on some measures. Few

demonstrated clinically significant change, although this is unsurprising given the

stringent criteria set. Of particular note, approximately 1/4 of students improved on

instrumental anger and total anger scores at post-test, whilst over 1/3 of students’

mindfulness scores increased at follow-up. Anger control however showed a similar

pattern to the ANOVA results, with around 1/5 of students deteriorating at follow-up.

20 See Leeds manual (Morley & Dowzer, 2014) for explanation of this.

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Table 8

No. of participants who have reliably changed at post- and follow-up

Pre-Post (n=15) Pre-Follow up (n=13 or 14)Improve* (CSC)

No change

Decline Improve (CSC)

No change

Decline

AARS instrumental

4 10 1 3 11 0

AARS reactive

2 12 1 1 13 0

AARS control

2 11 2 0 11 3

AARS total

4 10 1 3 10 1

SDQ conduct

0 15 0 1 12 0

SDQ hyp–inatt

1 13 1 4 (3) 5 4

MAAS-A 2 (1) 11 2 5 (1) 8 1*Statistical reliable improvement; CSC = where relevant, of those who reliably improved, no. clinically significantly changed

How feasible is it to provide an ACT intervention within the school context?

Attendance/Retention. High attendance rates indicate that it was feasible to

recruit and retain participants for the group in a school setting.

Treatment fidelity. Due to issues acquiring time in the school timetable and

limited staff availability, the weekly in-between session mindfulness practices were

not implemented at all for group one, and were inconsistently implemented for

groups two and three. In addition, timetable clashes resulted in sessions not always

being scheduled a week apart. For group three, the programme therefore occurred

over a period of four weeks. The introduction of a ‘rewards and consequences’

system was implemented halfway through group one to promote appropriate

behaviour.

Informal process notes. Facilitator’s interviewed one another and completed

informal process notes each week regarding their experience of running the

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intervention. As these process notes were not subject to formal analyses, they will

not be commented upon in detail here, however full details of this can be found in

appendix 13. Superficial review of these notes highlighted that facilitators reported

several benefits but also logistical challenges of running the groups in a school.

Qualitative

Four overarching themes were generated from the analysis, along with two

subthemes (see figures 3-6). Each theme was considered by the author in relation to

the research questions and the associated explanatory power provided. The Content

and Changes themes contained the richest information in relation to the research

questions, followed by Culture of the group, and finally Contextual considerations.

Theme 1: Content (figure 3). Reference was made to specific content of the

group with comments focussing upon its value, engaging content, its interactive/fun

nature, and its relatability. Mindfulness received a mixed audience, with some boys

valuing it, and others finding it disengaging. Vincent reported that despite sometimes

arriving at the group feeling angry, “the mindfulness process would actually help me

because...umm... my eyes would be closed and I would be relaxed so I wouldn’t

really be feeling any anger because I’d be noticing what’s around the room…”.

Similarly, when asked what was helpful, Thomas spoke about mindfulness: “like

when we sat facing the wall and like umm, we did that thing can’t remember what it

was called (Facilitator: “The mindfulness?”). Yeh mindfulness.” Others thought:

“Stuff that was unhelpful was like... […]...that mindfulness.” (Dean).

The boys made repeated reference to the ‘characters’ used in the programme,

which appeared to be memorable and engaging. Dean found the characters and the

idea of consequences of anger helpful, reporting “The thing that I found, like,

helpful, was...like...the wise warrior, and the mindless zombie and the consequences

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that would happen, if you don’t treat your anger properly.” Taylor valued and related

to the metaphor of the tiger representing his anger, reporting that “I can now know

that there’s a [sic] actual tiger, and the tiger’s inside of me, the tiger’s my anger, and

that I should walk beside my tiger...”

Many of the boys enjoyed the ‘urge surfing’ donut-eating task, aimed at

promoting acceptance/willingness to feel difficult feelings. Vincent appeared to

grasp the purpose of the task, alluding to the notion of resisting powerful urges, “[…]

what you did the urge thing […] and how we really want to eat it but try not to. And

then when we put it in our mouth, but instead of biting it straight away, you have to

umm let it stay in our mouth. And, that represents anger…”.

Whilst less salient in the data, the workbook was also received positively;

Kalim noted that he liked the workbook as “it made me write stuff...like, personal

stuff, like people who...is [sic] my inspiration.”

The questionnaires, and in particular the AARS, were not well received, with

many of the boys finding them disengaging, un-relatable, and too long. Gabriel

commented “you know when you do one yeh, and you find there’s like five more

pages, it just gets frustrating”. One of the most notable barriers was the language

used in the AARS. Freddie found this completely un-relatable, commenting “You

know where it says […] take it out on a [sic] animal […] That…that doesn’t make

sense, at all. […] Because, why would you hit umm a [sic] animal?”. Freddie’s

opinion was shared by many of the boys;

Gabriel : [...] it was stressful, irrelevant, and […] I found them, like,

what’s it called, offensive, because they were saying things like, starting a

fire like I’m mentally ill, like, who does that…what normal person?

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Some of the boys in group one in particular reported a mixed opinion on the

content; for example, Lequan reported that he had “...found it helpful, in some ways

and not helpful. […] …when we were talking about LeBron James […] ...that kind

of was helpful. But last week’s one was not really helpful, it was just boring.” Most

of the boys, however, reported an overall value and appreciation for the content.

When asked if they would recommend the group to their friends, Fazal, Callum and

Finley unanimously responded “Yeh”, with Fazal further adding that “it helps you to

like control yourself and it teaches you ways to like…[…] handle yourself in like,

tough situations.” Taylor compared his experience to a previous anger intervention,

reporting that “I was going to anger management for a bit, recently…yeh…couple

years ago. It’s rubbish. This…proper. This…I would say this is like, obviously

planned and stuff, this is proper anger management.”

Theme 2: Changes (figure 4). Notable changes reported by the boys

included having choice and control over how they respond, getting into less trouble

at school, and broader changes such as attitudes towards peers.

Freddie, Farouk and Taylor discussed having less fights, with Farouk

observing that “For me it’s surprising, ‘cause, like, every day I used to get in

trouble.” The three boys also reported receiving less disciplinary code violations at

school. In addition to the more obvious, behavioural changes, Thomas reported

subtler attitudinal changes towards his peers, observing “Like, I don’t pick arguments

with them for no reason”. In addition, some participants described thinking through

the consequences of their actions more. Lequan reported that in reference to teachers

“getting on my nerves” he has now come to the conclusion that “…if I started

shouting back at them...getting rude to them...it’s going to make the situation a whole

lot worse. And I could get in even more trouble than I already am in. So I just say

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‘okay’.” Lequan’s comment also highlights that participants reported learning that

they have ‘choice’ over how they respond when feeling angry. Gabriel commented

on this specifically, noting that;

What I learnt is that […] when I’m angry I have a choice of different paths to

take…whether to…carry on and get myself in more trouble, or calm down.

Participants also reported changes in terms of their skill development. Of

particular note, Freddie reported devising his own mindfulness exercises; “[…] I’ve

been doing the…umm, mindfulness thing, by myself as well. […] By making my

own one.” Others however found it more difficult to develop the mindfulness skills;

Finley reported struggling with the ‘quietness’ of the tasks, stating that “…it’s just…

it’s too quiet. My mind just keeps going away...”

Several participants made specific reference to the concept of ‘control’ in

relation to their anger. Whilst learning to ‘control’ emotions is not a desired outcome

of an ACT-intervention, the boys seem to be using the term in reference to

controlling their actions, e.g. Lemar referred to getting into trouble less since the

intervention. “‘cause I’ve controlled myself”.

Finally, whilst many participants reported tangible changes, a few struggled

to identify any. Despite Gabriel’s learning regarding ‘choice’, he found it difficult to

further identify specific changes, commenting that “…there might have been a few.

Might’ve been, but maybe I haven’t noticed them, but there might have been a few.”

Theme 3: Culture of the group (figure 5). The overall theme pertains to the

‘process’ variables associated with groups, and consists of two subthemes;

‘Interpersonal factors’, and ‘Structural factors’. Within the interpersonal factors

subtheme, the benefits of being in a group, and the support and normalisation this

provides emerged as a common thread across all groups. Omarr commented on the

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support the group provided, observing that “When you say something personal, you

know that... you know that whatever you say can be...you can be helped by other

people.” In addition, Gabriel referred to the benefits of ‘normalising’, stating that “…

if you’re in a group […] you know that, it’s not only you that goes through what

you’re going through. Like, other people, go through it too.” Fazal compared being

in a group to a one-to-one session, commenting on the reduced ‘awkwardness’ the

group provides, as well as the opportunity to learn from peers,

In the group, you can hear more people’s ideas, and what they think, so you

can use that as well for advice.

The relatability of facilitators was mentioned by several participants, with

many commenting on the desire to have a facilitator who had experienced similar

difficulties to them. Thomas felt he would like to have had someone participate in the

group “that’s experienced, like, building up loads of anger and maybe committing a

crime or something like that...”. Similarly, Finley described how he would like a

facilitator who misbehaved at school and had a difficult life, but who had now turned

their life around, stating that an individual with these experiences “can understand

[…] …how you feel. […] …because they’ve been through it.” However not all

participants thought a ‘similar’ facilitator would be helpful, citing concerns about

whether they would feel able to be open;

Callum: …say if […]…there was a black man sitting there, we’ll probably be

more…not…more connective… (Another group member: More open). Yeh

we…we won’t really be more open…

The structural factors subtheme refers to the foundations of a group that are

not linked to content or interpersonal variables, but are fundamental to the success of

groups, for example boundaries, behaviour management, confidentiality, etc (see

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figure 5). Trust and confidentiality were discussed as important, with participants

having differing views on whether they felt this was present. Omarr felt that he could

not trust the facilitators completely “…because you don’t work at the school, and

then you could just go off and tell other people…”. Conversely, Gabriel felt his

confidentiality was more protected with external facilitators, expressing concern

about teachers “[…] in the staff room, gossiping about your business...” Adopting a

slightly different perspective on confidentiality, Callum commented on the ‘safety in

numbers’ provided by the group;

…‘cause you know other people sharing their feelings you might as well,

‘cause you know that, they’re going to keep your feelings and you’re going to

keep theirs.

Participants commented on ‘behaviour management’, with some observing

the importance of having rules and behaviour being managed. Omarr felt that the

presence of a particular school-based facilitator was helpful as “She’s the one that

made us, like, behave properly in the session.”. Freddie, Taylor and Gabriel

discussed the rules and consequences in the group, and agreed that rules were

“alright”, highlighting the safety this provides.

Theme 4: Contextual considerations (figure 6). This consisted of two sub-

themes; ‘Practical factors’ and ‘Inter- and intra-personal factors’. The overall theme

referred to the factors outside of the group that influenced the boys’ perceptions and

experiences of the group, and their capacity to change. The practical factors

subtheme focused on logistical issues associated with group attendance, whilst the

inter- and intra-personal factors subtheme focused on the relational and individual

influential factors.

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Within the practical factors subtheme, discussion around ‘pacing’ of the

group occurred recurrently, in reference to frequency of sessions, length of sessions,

and timing of sessions. The overall picture was one of the boys wanting ‘more’;

Fazal indicated a preference for longer session duration, stating that “…if its longer,

you can get like…more…more advice and like…umm, like, more ways to help you.”

Thomas however would have preferred increasing the total number of sessions,

citing a need for more discussion time; “I think we should’ve have done it maybe

twice a week […] ‘cause there might have been something you wanted to say and

then for the next week we didn’t.” Finley echoed a need for more time for discussion,

observing that more sessions would enable opportunity to “talk more in detail about

the wise warrior and the…the mindless zombie, and role models and all that.”

The boys also discussed how the group fit into their other commitments.

Sometimes the group was seen as a better option to their alternative; for example,

many of the boys appeared to make reference to the group being an easier/better

option than attending their lessons;

Gabriel : So that I can miss maths.

Dean: ‘Cause double history is like the worst lesson ever.

At other times, the group was seen as conflicting with more important

demands. For many of the boys, this was particularly noticeable when the question

was posed of holding the group after school rather than during school-time. Farouk

observed that “after school…got stuff to do, like playing football”, and Lequan

shared a similar perspective, stating that “people have got things to do after school”.

However this view was not unanimous; Thomas expressed reservations about the

lessons he was missing in order to attend, stating that he “…probably would have

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preferred it after school because, umm, my ***** lessons is like PSHE so its

teaching me different things throughout society...”.

In addition to the above ‘practical’ contextual considerations, the boys also

mentioned various inter- and intra-personal factors that influenced their experience

of the group, and their ability to make changes. In particular, some of the boys

mentioned having a ‘history’ with teachers which meant that they, at times, felt as

though they were pre-judged with regard to any incidents of difficult behaviour. For

example, Farouk reported that “…if I tell the teacher, he won’t listen… […] …I told

him, that it wasn’t me, and then they wouldn’t listen.” The implication here being

that, for some of the boys, they were trying to make changes in a context of a

negative pre-judgement, which was difficult for them.

The boys also talked about other ‘external influences’ that affected their

pathways to change. Taylor described parental pressures as promoting change; “…

this is the exact same words my mum said to me. If you don’t get GCSEs…or don’t

get a good GCSE by the end of this…ermm, by year 10, you’re not coming to my

house again.” Gabriel observed the impact of school pressures and maturity on

promoting positive change, commenting that year 9 entails “more responsibility” and

that “GCSEs is [sic] around the corner”.

Follow-up focus group. The brief ‘check-in’ follow-up focus groups were

not subject to the same rigorous analysis as the main, post-group focus groups;

however they were nonetheless transcribed and reviewed. There was no obvious

evidence of contradictory or additional themes emerging. Furthermore, the follow-up

focus groups revealed that the boys had continued to retain much of the content from

the group. Members of all groups recalled the ‘wise warrior/mindless zombie’

metaphors, and the ‘urge-surfing’ exercise. Other key details remembered included

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the use of ‘LeBron James’ as a role model, the use of the ‘tiger’ to represent anger,

the idea of taking different pathways, and several of the interactive exercises

including mindfulness, the ‘accents’ defusion exercise, the ‘self-as context’ weather

exercise, and the ‘falling in love with a spot on the floor’ exercise.

Reflexive account. The process of gathering, transcribing, analysing, and

summarising the qualitative data required the author to adopt a reflective-scientist-

practitioner perspective. Given the author’s competing roles of devisor, facilitator

and evaluator of the intervention and the focus group, it was important to guard

against competing interests in the process of interacting with the qualitative data. The

author adopted a semi-structured format to the focus group to promote adherence

with a pre-set objective agenda (as opposed to the author’s personal agenda), and

adopted a critical-realist position, relying largely on the manifest content of

transcripts to reduce the opportunity for bias in interpretation. A full reflexive

account of this process can be found in appendix 14.

Figure 3. Theme

1: Content

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Figure 4. Theme 2: Changes

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Figure 5. Theme 3:

Culture of the group

(and associated subthemes)

123

Figure 6.

Theme 4:

Contextual

considerations (and associated subthemes)

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Discussion

How acceptable is an ACT-based intervention to adolescent males with anger

difficulties?

High attendance levels and the qualitative data suggest that the intervention

was acceptable to participants. The boys reported favourably on the content,

engaging well with key metaphors and exercises, and requesting ‘more’ of the

intervention. The majority of the boys valued being in a group, appreciating the

support and normalisation provided by peers, and having the space to express

themselves. Mindfulness received a mixed reception, with some boys valuing it and

others finding it difficult to participate in fully. Given that research suggests that

mindfulness is generally received positively by young people (e.g. Huppert &

Johnson, 2010), one explanation for some boys failing to engage with it may be the

lack of dosage (particularly the lack of in-between session mindfulness practices).

This may have resulted in inadequate mindfulness skill development, and consequent

disengagement. The boys had varied responses to external facilitators, with many

valuing the fact that facilitators were separate from the school. Some however felt

cautious of trusting external facilitators, whilst others mentioned the addition of a

more relatable facilitator would have been helpful. Overall, the results suggest the

group is an acceptable intervention to the participants.

How acceptable are the measures used?

Several of the outcome measures were unacceptable to participants. Issues

included poor completion (VLQ), difficulties relating to content (AARS), floor

effects (AARS, SDQ), poor internal consistency (SDQ), and logistical difficulties

(MTPT). The exception to this was the MAAS-A, which did not evoke strong

antipathy from the boys and was completed well.

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The qualitative data revealed that the boys generally found the questionnaires

too long and there were too many of them; this may explain the poor completion of

the VLQ, particularly given the frequency (weekly) of administration. The AARS

produced notable floor effects and was disliked by nearly all, who reported finding

many of the questions only applicable to a much higher risk client group. This was

supported by the fact that the ‘normal population’ (normative data provide in the

AARS manual from a US sample of same age boys) scored ‘worse’ on this measure

than the participants in this study at pre-intervention. Cross-cultural differences may

exist between US and UK adolescent males and the manner in which they express

anger, rendering this measure less applicable to the study participants.

The low alphas on the SDQ indicate difficulties with this measure, however,

as Cortina (1993) observed, alpha is affected by the number of items in a scale. The

low number of items per scale in these questionnaires, as well as the small sample,

may therefore partially explain the low (even negative) alphas seen. Nonetheless, the

boys also lacked motivation to complete the questionnaires, which could have

translated into careless answering. The floor effects further question this measure’s

suitability for this client group.

The MTPT appeared to have good face validity, and may be a useful measure

to revisit in future studies as a behavioural measure of frustration tolerance,

providing the logistics of completing the measure are established in advance.

The results suggest that the VLQ, AARS and SDQ were unsuitable for this

client group, whilst the MAAS-A and MTPT may be helpful to retain in future

research.

Following intervention, were there any changes observed in the adolescents on

anger and ACT variables?

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The quantitative and qualitative data revealed a mixed picture of results in

regard to changes. Firstly, all quantitative results require caution in interpretation,

and should be considered within the context of the aforementioned difficulties with

the questionnaires. Furthermore, the small sample size and associated lack of power

reduces the likelihood of finding significant changes in large scale analyses.

ANOVAs showed that differences between time-points were, for the most

part, non-significant. The exception to this was a significant reduction in anger

control from post-test to follow-up. It is unclear why anger control decreased

between these two time-points; this may have been due to chance, or related to issues

with the questionnaire. Many of these questions21 relied on problem-solving skills

and therefore executive functioning abilities, which are not fully developed until well

into our twenties (e.g. Sowell, Thompson, Holmes, Jernigan, & Toga, 1999). One

question was phrased as a double-negative, which resulted in the boys often

answering in a manner inconsistent to the rest of their results. Furthermore, two of

the questions reference “ignoring”; from a theoretical view point, ACT is not about

increasing one’s capacity to “ignore”, but instead learning to notice, accept and be

with difficult feelings.

Effect sizes provide a measure of the size of differences and are arguably

more useful for interpreting results than statistical significance. Indeed, focusing

solely on p-values has been subject to criticism, as they reveal nothing about the

magnitude of differences and are reliant on sample size (e.g. Sterne & Smith, 2001;

Sullivan & Feinn, 2012). In general, the measures that might be most expected to

change (instrumental anger, reactive anger, total anger, SDQ conduct, MAAS-A),

displayed (non-significant) improvements in the desired directions. Whilst other less

21 See appendix 15 for a breakdown of the questions in this subscale.

127

directly relevant measures moved (non-significantly) in the undesired direction (SDQ

emotional, SDQ internalising). The exceptions to this general rule are SDQ

externalising which showed no change, and SDQ hyperactivity-inattention and anger

control, which moved in an undesired direction.

The possible reasons for anger control’s suggested decline have already been

discussed. One explanation for the possible undesired changes in SDQ emotional,

internalising and hyperactivity-inattention could be that the boys’ increased levels of

mindfulness raised awareness of their internal states, resulting in them being more

alert to (and thus reporting) more difficult feelings. The boys may have lacked the

ability to transfer their mindfulness skills to ‘non-angry’ feelings (e.g.) ‘restlessness’,

due to a lack of dosage of mindfulness, and not enough explicit discussion around the

transferability of these skills to other feelings. The lack of change in SDQ

externalising can be explained by the opposing direction of changes of SDQ conduct

and SDQ hyperactivity-inattention, which constitute this scale.

N=1 results show that the majority did not change reliably, a minority reliably

improved on some measures, and a small minority reliably declined. The intervention

in its current form may therefore be sufficient to prevent deterioration, as opposed to

promoting significant positive change. This fits within the broader picture of the

boys’ pre-intervention scores predominantly residing in the ‘normal range’ and it

thus being very difficult to demonstrate positive change. This may also further

explain the non-significant changes from the ANOVAs. In light of this, the fact that

some effect sizes in the appropriate direction were nonetheless discovered is a

promising result.

Qualitative data suggests that the boys experienced a number of positive

changes including having more choice and control over their responses when angry,

128

receiving less disciplinary code violations at school, thinking through the

consequences of actions more, and positive shifts in attitudes towards peers. Skill

development was a mixed picture, with some boys feeling that they gained

mindfulness skills, whilst others struggled with this. The lack of between-session

practice may explain this mixed result.

Overall, the qualitative data suggests the boys experienced several positive

outcomes from attending the group, which received mixed support from the

quantitative data. The less robust quantitative outcomes may be due to the small

sample, low pre-intervention scores, and difficulties with the questionnaires.

How feasible is it to provide an ACT intervention within the school context?

Treatment fidelity data highlighted logistical challenges with running the

intervention in a school setting, particularly with regard to it not being prioritised in

the school timetable. However the participants attended regularly and were generally

happy to attend during the school day. Participants (and facilitators, as reported in the

informal process notes) both felt ‘more’ of the group would have been helpful.

In summary, the boys’ qualitative data and quantitative attendance data

suggest it is feasible to run the group in school largely as it is, with a preference for a

longer duration. The treatment fidelity data implies that greater logistical integration

of the intervention into the school timetable would assist in the feasibility of

continuing to implement it in a school-setting.

A summary of the overall conclusions to each research question is provided

in table 9.

Table 9

Summary of results

Research question Quantitative Qualitative Overall summary

129

results resultsHow acceptable is an ACT-based intervention to adolescent males with anger difficulties?

Very acceptable Very acceptable Very acceptable

How acceptable are the measures used?

Largely unacceptable

Largely unacceptable

Largely unacceptable

Following intervention, were there any changes observed in the adolescents on anger and ACT variables?

Mixed picture of results

Several positive changes identified

Evidence for some positive changes, which requires further replication using more appropriate quantitative measures

How feasible is it to provide an ACT intervention within the school context?

Feasible Feasible - with some modification, particularly in the initial set-up of the group

Feasible, with some suggested alterations

Limitations

Given the feasibility nature of the study, it unsurprisingly experienced some

methodological difficulties. Fidelity to the treatment manual was not always

achieved, limiting the internal validity of the findings. As this was the first time the

group had run, small changes were made by the facilitators, for example the

introduction of a rewards and consequence system during group one. Further fidelity

issues included the lack of consistent between-session mindfulness practices, and the

combining of some sessions into a double session. Whilst these issues reduced the

internal validity of the findings, the resultant effect is likely to reduce treatment

effects, as the boys had less time to practice and process the material. The potential

value of the intervention may therefore be underestimated.

130

The small sample and lack of control group limits the inferences that can be

made about generalisability and cause-effect relationships. However the boys’

qualitative feedback suggests that they gained specific benefits from the group itself,

in addition to other external influences on change. In addition, the reliance on SLT

members to select boys with “mild-moderate” anger difficulties is dependent on a

somewhat subjective assessment of the boys’ difficulties. Whilst a screening tool

may have provided a more objective assessment for inclusion into the intervention,

given this was a school-based study, the ecological validity provided by using

teacher assessment and their knowledge of the boys was deemed a helpful part of the

inclusion process.

The outcome measures had several limitations already described. In addition,

the reliance solely on self-report data is limiting. The mixed-methods approach does

however provide an added layer of depth and understanding. In addition, the 3-month

follow-up is a strength of the study, where many previous studies have restricted

evaluation to pre- and post- data (e.g. Bundy, McWhirter, & McWhirter, 2011;

Cheng et al., 2008; Down et al., 2011). Furthermore, the results are due to be

combined with a parallel research project at a later date which is investigating the

teachers’ perspectives on changes in the boys, as well as school-based behavioural

data.

It is possible the boys may have filtered their focus group feedback, as they

wanted to continue to participate in the intervention in order to miss lessons. In

addition, the qualitative data was gathered and analysed by the main researcher, who

was also the devisor and co-facilitator of the group. A potential implication of this is

that the boys may have attempted to protect the feelings of the facilitator in their

feedback. However, facilitators explicitly encouraged the boys to be honest in their

131

feedback, and transcripts revealed several occasions when the boys were able to

provide critical feedback.

Implications of study: Existing research

Research into ACT is still in infancy compared to the more traditional first-

wave CBT approaches. This study adds to the overall volume of research on ACT, as

well as the literature specifically on anger, and on adolescents. To this author’s

knowledge, there are no existing studies evaluating ACT for anger in adolescents.

Whilst a relatively strong evidence base for traditional CBT exists (e.g. Sukhodolsky

et al., 2004), the lack of diversity of interventions, interventions targeted specifically

at males, and UK-based studies, was a significant gap in the literature. “Taking

ACTion on Anger” provides the first-step in developing an alternative intervention

for adolescent males with anger difficulties.

The transdiagnostic nature of ACT may also provide much broader benefits

than some of the more traditional approaches to anger management. For example,

mindfulness interventions for adolescents with a wide range of presenting difficulties

have been associated with improvements in wellbeing, greater resilience, increased

sustained attention, improvements in sleep, and even reduced blood pressure (see

Weare, 2012). Adolescents in receipt of this intervention may therefore demonstrate

benefits beyond those simply pertaining to anger.

Implications of study: Future research

The study has provided preliminary evidence on the acceptability and

effectiveness of “Taking ACTion on Anger”, which was, on the whole, well-received

and appears to have resulted in some positive changes for the participants. Future

research requires replication of the intervention in the context of a larger sample and

control group.

132

A useful future development would be to consider an intervention that is

longer in duration (e.g. a term, rather than a half-term) and/or is accompanied by

later ‘booster’ sessions. Booster sessions have previously been suggested as a way of

maintaining treatment gains (Herrmann & McWhirter, 2003). Farrell, Meyer,

Sullivan and Kung (2003) found that their 12-week booster intervention produced

several positive outcomes, particularly for boys or for those presenting with higher

pre-test violence levels. A desire for ‘more’ of the intervention arose in the

qualitative and informal data, and this extra session time could be used for greater

discussion of the flexibility of mindfulness skills and their applicability to other areas

of the individuals’ life, to encourage transferability of this skill.

Future research should also consider the systemic context in which

interventions occur. Whilst the intervention was deliberately targeted solely at the

adolescents with the aim of developing a low-cost intervention, several of the boys

commented on the difficulties of a ‘bad reputation’. Relationships with teachers has

previously emerged as a difficulty for similar adolescents (e.g. Humphrey & Brooks,

2007). Future research should consider supplementing interventions with

systemically-informed conversations with school staff (e.g. regarding problem-

saturated narratives), to enable greater transferability of learnt skills into the wider

school environment.

More comprehensive preparatory work with schools regarding the logistics of

running the intervention is also recommended. This should include spending more

time embedding the intervention within the school timetable, early identification of a

school-based facilitator who has capacity to co-facilitate, and wider promotion to the

whole school of the intervention. Consideration should be given to selection of

facilitators, with a mixture of school-based and non-school based appearing to strike

133

a good balance. Additionally, consideration should be given to relatability of

facilitators.

Finally, future research should consider alternative quantitative outcome

measures, and reducing the number of measures employed. The result suggests the

SDQ and AARS are not appropriate for this client group, however researchers may

wish to retain the MTPT and MAAS-A, and consider an alternative self-report

measure of anger, for example the Reactive and Proactive Aggression Scale (RPAS;

Raine et al., 2006). The RPAS is shorter than the AARS (23 items), and appears to

have less ‘extreme’ examples of aggression in its questions. It has shown good factor

structure and internal consistency (α=0.81-0.91) in the author’s initial validation

study on a US sample. The questionnaire has since been translated and validated in a

Dutch sample of children, adolescents, and adults (α=0.83-0.91; Cima, Raine,

Meesters, & Popma, 2013) and Italian “non-clinical” adolescents (α=0.75-0.86;

Fossati et al., 2009), suggesting it may be transferable cross-culturally and more

suitable for lower-risk client groups. Implicit behavioural measures, parent

perspectives on change, and an extended follow-up period, would also provide more

robust evaluation of the intervention. Limited time and logistical barriers to gathering

the computer-based behavioural data prevented us from gathering this.

Conclusion

“Taking ACTion on Anger” is an acceptable intervention for adolescent

males with anger difficulties. Preliminary evidence provides tentative support for its

effectiveness, particularly in relation to qualitative data, however this requires further

validation. Future research should consider employing a larger sample size with

control group, extending the duration of the intervention, investing greater resources

in the preparatory phase of delivering the intervention, working systemically with

134

schools to increase transferability of intervention gains, and employing alternative

outcome measures.

135

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List of Appendices

(Appendix 1 – Guidelines for Authors - Removed for E-thesis 146)

(Appendix 2 – Copies of Measures – Removed for E-thesis 158)

Appendix 3 – Clinical Cut Offs: SDQ and AARS 162

Appendix 4 – Focus Group Interview Schedule 163

Appendix 5 – Examples of Process Notes 165

Appendix 6 – Follow-Up Focus Group Interview Schedule 167

Appendix 7 – Intervention Protocol 168

Appendix 8 – Qualitative Analysis Audit Trail 184

Appendix 8a – Reference Document 1 186

Appendix 8b – Reference Document 2 200

Appendix 8c – Reference Document 3 204

Appendix 8d – Thematic Map 1 215

Appendix 8e – Thematic Map 2 216

Appendix 8f – Thematic Map 3 217

Appendix 8g – Examples of Coded Extracts 218

Appendix 9 – Ethical Approval 225

Appendix 10 – Information and Consent Forms 226

Appendix 11 – Normality Analyses 232

Appendix 12 – Additional Reliability Analyses 240

Appendix 13 – Informal Process Notes Discussion 243

Appendix 14 – Reflexive Account of Qualitative Analysis Process 244

(Appendix 15 – Anger Control Subscale Question - Removed for E-thesis 248)

145

Appendix 1 – Guidelines for Authors - Removed for E-thesis

146

Appendix 1 – Guidelines for Authors - Removed for E-thesis

147

Appendix 1 – Guidelines for Authors - Removed for E-thesis

148

Appendix 1 – Guidelines for Authors - Removed for E-thesis

149

Appendix 1 – Guidelines for Authors - Removed for E-thesis

150

Appendix 1 – Guidelines for Authors - Removed for E-thesis

151

Appendix 1 – Guidelines for Authors - Removed for E-thesis

152

Appendix 1 – Guidelines for Authors - Removed for E-thesis

153

Appendix 1 – Guidelines for Authors - Removed for E-thesis

154

Appendix 1 – Guidelines for Authors - Removed for E-thesis

155

Appendix 1 – Guidelines for Authors - Removed for E-thesis

156

Appendix 1 – Guidelines for Authors - Removed for E-thesis

157

Appendix 2 - Copies of Measures – Removed for E-thesis

158

Appendix 2 - Copies of Measures – Removed for E-thesis

159

Appendix 2 - Copies of Measures – Removed for E-thesis

160

Appendix 2 - Copies of Measures – Removed for E-thesis

161

Appendix 3 – Clinical Cut Offs: SDQ and AARS

SDQ. Clinical cut-off categories for the SDQ are displayed below.

Interpretation category

SDQ subscale

score

Close to

average

Slightly raised

(slightly lowered

for prosocial)

High (low

for

prosocial)

Very high

(very low for

prosocial)

Emotional

problems

0-4 5 6 7-10

Conduct problems 0-3 4 5 6-10

Hyperactivity 0-5 6 7 8-10

Peer problems 0-2 3 4 5-10

Prosocial 7-10 6 5 0-4

Total difficulties 0-14 15-17 18-19 20-40

AARS. The AARS manual includes a guide to interpretation which requires

converting raw scores to T scores. T scores are then interpreted in reference to a

comparative normative sample. T scores can then be categorised from very low to

very high, allowing calculation of the number of participants falling above clinical

threshold (moderately high and above for IA, RA and TA, and moderately low or

below for AC) at each time point.

162

Appendix 4 – Focus Group Interview Schedule

General experience of group

1. Talk about your experience of participating in the ACT group:

What were the helpful aspects?What were the unhelpful aspects?What would you change?

Logistics of the group

2. How did you find the process of being in a group (as opposed to individual support)?

3. How did you find the format of the group?

Weekly sessions with in-between practices?Missing school time – would you prefer after school?Length of sessions/Total number of sessions?How helpful was having a workbook to follow?

Effects of group

4. Have you noticed any changes in your life since completing the ACT group?

Do you feel better/worse/ the same?Why do you think these things have changed?

Logistics of the data collection

5. What was your experience of completing the questionnaires?

Were they too long?Did they make sense to you?

a. What about the computer task?

Future planning

163

6. If you were designing a group for boys your age with anger difficulties what would you like in it?

What would you not like in it?

7. Is there anything else that you wanted to feedback?

164

Appendix 5 – Examples of Process Notes

Week x, group x

The logistics of data collection was quite stressful due to other events

occurring at the school, room changes, young people not being in the correct room

when trying to locate them, etc. We had four young people who attended the group

today (one couldn’t be found, and one didn’t want to attend). Only one young person

managed to complete the computer task due to these pre-group stressors. This was a

stressful start to the group, and we were concerned about the effect the

disorganisation of the session would have on the participation of the boys and the

tone of the group. However the four boys participated and behaved extremely well in

the session. They wanted to contribute a lot and the knowledge of school penalty

points and in session ‘reward and consequence’ points seemed to manage their

behaviour. They shared good examples, participated well in the exercise about who

inspires them, and completed the workbook well. Overall, it was a very positive start

to the group (logistics aside) – possibly better due to small group, or “better

behaved” young people attending this group? Facilitators both felt that separating

two of the boys from the start was positive, implementing the rewards and

consequences chart from the start was helpful, and that they felt more authoritative

and more confident in running the group this time round. The school facilitator was a

calming presence in the room and the facilitators both feel she will be an asset to the

group.

Week x, group x.

Four boys attended today. School facilitator still unable to do mindfulness in

between practice. Two boys turned up a bit late so session started a bit late.  Overall

really positive session. Facilitators spent time recapping main themes and trying to

165

convey key messages of controlling actions rather than feelings, and sitting with

difficult feelings. All boys participated well today, definitely encouraged by reward

chart. They sat quietly in the mindfulness, and participated on both main tasks of the

session. I felt able to draw more out of them today, rather than giving them too many

answers (possibly due to time being less pressured). School facilitator was stricter in

terms of giving out consequence points today, but I was impressed with one boy

continuing to stay engaged and earn his reward points back (rather than disengaging).

They were all able to urge surf and I felt this task conveyed message of control really

well. Interesting how positive facilitators came away feeling today, feeding off the

participation and positivity of the boys.

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Appendix 6 – Follow-Up Focus Group Interview Schedule

1. What can you remember from participating in the ACT group?

a. What made you return each week?

b. If you had to tell someone about the group, what would you say?

2. Have you been able to use any of the ideas we talked about in your day-to-

day life, since finishing the group?

a. If you haven’t been able to use them, why do you think this is? What

barriers have you come up against?

3. Have you noticed any further changes in your life since completing the ACT

group? (Do you feel better/worse/ the same? Why do you think these things

have changed?)

4. If I/We asked your teacher/ and carers/other family members what would

they say was different about you?

5. Would you be interested in participating in another group like this?

6. Now that more time has passed since you completed the group, are there any

changes you would make to the content or how the group is delivered?'

7. Anything else you wanted to feedback?

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Appendix 7 – 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

Values 15 mins Include space in workbook

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examples

Group Rules & Commitment Ask 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 quiz Young people to complete workbook individually quickly, and then we go through Powerpoint with explanations below. 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

Defusion

15 mins Buzzers

Powerpoint with myths/facts on them.

Powerpoint with zombies, wise warrior, and tiger images and key words about each one.

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Anger will pass with time – not due to ventingFact 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.

Defusion

Defusion

Committed Action

Acceptance

Acceptance

Experiential avoidance(Dropping the struggle)

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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.

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

Present moment

Defusion

10 mins

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Really important part of the course - like learning a musical instrument. If you never practice, you won't develop the skills.

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.

In-between session mindfulness practice at school? NotesAs in session Give copy of mindfulness script to session facilitator

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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

Session ObjectivesSession 2Pursuing your values with courage and strength

Explore the following:Cost of acting on angerValuesChoice pointCommitted action

Activity ACT Principle Duration ResourcesMindfulness exercise – Mindfulness of body after doing exercise

Debrief – 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 moment

Defusion

10 minutes 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 minutes Workbook

Introducing values (and goals) Values 20 minutes Powerpoint/Workbook

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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 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 18th 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 –

Values v goals cards

Complete section in workbook

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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.

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 minutes Powerpoint/workbook

LeBron James biography

Powerpoint collage of LeBron James experiencing difficult emotions and separate one of success.

Complete Valued Living Questionnaire (VLQ) 5 minutes VLQs

Homework task First: Say one thing you have learned today?Set a value guided goal to complete for the following session Valued Living Questionnaire (VLQ) if not time in lesson

5 minutes Workbook

Mindfulness practice at school NotesAs in session Give copy of script to session facilitator

Session Objectives

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Session 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 Resources

Mindfulness 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=eRCJow2tKso

Mindfulness 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?

Values

Committed 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

Acceptance / Willingness to feel

Choice over behavioural responses

15 mins Videos of Phil Mitchell https://www.youtube.com/watch?v=Bt0m3VLnG34

Powerpoint of tiger/zombie and wise warrior with relevant characteristics superimposed.

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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).

Values

Another metaphor....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

Self-as-context

5 mins Laminated pictures of the sky, lightening, clouds, sun, etc.

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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.

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

5 mins Homework summary on powerpoint and in workbook

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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.

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

Acceptance

Dropping the struggle

10 mins Script for falling in love with spot on floor

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them, and be a wise warrior.

What we can control is our actions - what we do with our mouths, hands and feet.

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.

Acceptance / Willingness

10 mins Donuts

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 session Review homework

Value guided goalWhat 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

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Willingness action plan: Begin to complete in class and share – young people to continue to complete at home

Give 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 8 – Qualitative Analysis Audit Trail

All focus groups were facilitated by the author.All recordings were transcribed by the author to gain initial familiarity with the data. The table below describes the overall process; accompanying reference documents follow the table. Given that the researchers observed that group one was distinct from groups two and three in terms of the higher level of behavioural difficulties, group one’s focus group was analysed first to ascertain if emerging themes were distinct from groups two and three. When reviewing the qualitative data that emerged it was felt that the overall themes were similar, and as a result the three groups were combined in the analysis.Date Summary of work done Reference document12th August 2016

Reading and deciding on approach. Focus on entire data set, hence largely data driven (rather than theoretical), realist, and focusing mainly on manifest content with some latent content analysis (at the level of understanding inferred meaning from body language, tone of voice, etc, as opposed to further interpretation). Critical realist model.Re-listened to recording of group 1, post focus groupFirst reading of group 1, post focus group – notes re possible codes made

Document 1

Second reading of group 1, post focus group – notes re possible codes made

Document 1 and later added to transcript

15th August 2016

Third reading of group 1, post focus group – notes re possible codes made

Document 1 and later added to transcript

Re-listened to recording of group 2, post focus group

First reading of group 2, post focus group – notes re possible codes made

Document 1 and later added to transcript

Second reading of group 2, post focus group – notes re possible codes made

Document 1 and later added to transcript

16th August 2016

Code generation and organisation Document 2

22nd August

Draft coding of transcripts – condensing information from first two

See transcripts

184

2016 readings into draft codes. Read over twice to ensure all codes had been considered.Meeting with supervisor for initial code and theme review/generation

Document 3

23rd August 2016

First and second readings and re-listening of group 1 individual interview

Annotated directly on transcript

Coding individual interview – compared to codes already generated from first 3 focus groups to see if any new codes developed. No new codes.

All directly on transcripts

Theme generation, recoding and reorganising to generate coherent themes

Document 3, and theme maps 1 and 2

5th September 2016

Refining of themes and codes, numbering frequency of codes

Document 3, theme map 3

Generating final themes Document 3, theme map 3

Beginning to extract examples from transcripts for results section

11th

December 2016

Re-reading of transcripts with “fresh eyes” to check for any missed/unnecessary codes

Document 3, final theme maps (main body)

Tweaked two code names to better represent data

Document 3, final theme maps (main body)

Above led to generation of additional “no change” code

Document 3, final theme maps (main body)

Theme salience decided upon in relation to research questions posed

Empirical paper

Supervisor reviewed transcripts to check validity of codes and themes

185

Appendix 8a – Reference Document 1

Inductive thematic analysis – initial ideas on codesAll of the information below (apart from “initial reading of group 1 post focus group notes”) were later added directly to transcripts for ease of reading. The author did not initially annotate directly on transcripts to avoid subsequent readings being influenced by previous thoughts on codes (i.e. allowing each reading to look at “blank” transcripts). After the 3rd reading of group 1, and the 2nd readings of groups 2 and 3, the notes below were added to the transcripts. 12 th August 2016

Initial reading of group 1 post focus group

Line 6 – control Line 8 – relaxed Line 13 – helpful and not helpful, boring

Line 15 – characters, consequences

Line 17 – mindfulness unhelpful

Line 20 – making new friends

Line 22 – how to interact with people from different backgrounds

Line 26 – meeting new people

34 – meeting new people – “I know him”

44 – benefits of group – being helped by other people

46 – dull on own – better in group. Group can be helpful and unhelpful – distracting/difficult

50 – new ideas – external facilitator

52 – trust 58 – trust 65 – teachers serious, facilitators can take a joke

69 – importance of school facilitator – balance between behaviour management and not disliking teacher

71/73 – facilitator 93 – preoccupation with lessons being missed and wanting to tailor timing of intervention to fit with this.

99 – increased frequency 111 – increased duration Theme of wanting to miss school time??

118 – missing education lessons bad thing

Theme of not wanting it to impact on lessons?

122 – value of workbook being overlooked?

124 – less angry at my sister

131 – learning to think before act

133 – tiger is calmer – use of group metaphor

144 – exerting more thought and self control in reactions

146 – not answering back 148 – thinking through the consequences

154 – concerned about questionnaires – these don’t relate to me? I would never have thought of that

158 – questionnaires – weird

167 – too many questionnaires

168 – questionnaires were repetitive

190 – more games 193 – play fifa

199 – snacks 204 – donut activity – good

Theme of interactive activity??

186

211 – angry frustration games

Second reading of group 1 post focus group

4 – wise warrior – use of character good?

6 – control - Code: distal impact of group?

8 – group and mindfulness -> relaxed Code: immediate emotional impact of group?

12 – LeBron James – helpful – Code: making group engaging, characters they can relate to?

15 - characters and consequences helpful – Code: metaphor, personalised to individual (consequence)?

19 – it was the same things – Code: not engaging, repetitive, didn’t see the point?

20 – meeting new friends – Code: broader impact of group/unforeseen benefits?

22 – taught me how to interact with people from other areas – Code: broader skill development?

26 – met new people

30 – are you going to put it on in assembly? Code – confidentiality concerns?

34 – meet new people: Code – broader impact of group

44 – helped by other group members Code: effect of peers/group process?

46 / 48 – peers also distracting. Code: effect of peer/group process

50 – outside facilitators bringing something new. Code: fresh perspective?

52/56/58 – can’t trust: Code trust/confidentiality

65 – facilitators can take a joke Code: group process, authority?

69 / 71 – school facilitator important: Code group process, authority?

80s and 90s – additional sessions during specific lessons. Code: group as soft option?

118 – not wanting to miss lesson. Code: school v group tensions?

120 – liked the workbook, made me write personal stuff. Code: personalisation of group

122 – missed lots of pages in workbook that were important. Code: value of group, personalisation important?

124 – less angry at my sister. Code: anger related change

131 – think before you act. Code: impact of group?

133 – tiger is calmer. Code: using metaphor/characters from group/ impact of group

138 – c point. Code: impact of group, consequences

144 – c point, now comment why? Code: impact of group, control?

146/148 – don’t answer back, don’t want to make the situation worse. Code: making choices? Consequence?

154 – questionnaires concerning. Code: mismatch between

160 – questionnaires weird. Code: detrimental effects of group?

190 – more games. Code: group as a soft option? Group more interactive?

187

individuals and measures? Inappropriate measures? Detrimental effects of group (concern)?

Labelling individuals?

200 – snacks. Code: group as a soft option?

203 – donut activity. Code: use of metaphor, interactive

212 – more frustration games. Code: interactive, soft option, not taking seriously?

15 th August 2016 Third reading of group 1 post focus group

2 – characters/metaphors = helpful.

6 – control; Code: controlling anger

8 – mindfulness = relaxing. Code: immediate impact of group; relaxation; skill learning

13 – some parts helpful, some parts not helpful. Code: ambivalence? Relatable content = good, some = boring

15 – characters = good, consequences = good. Code: relatable content

17 – mindfulness – always the same. Code: lack of clarity around purpose?

20/22 – meeting new people. Taught me how to interact with people from surrey. Code: unforeseen benefits of the group? Broader skills development

26 – met new people. Code: benefits of group? Importance of peers? Broader skill development?

30 – concerns over recording being played in assembly. Code: group process? Trust?

44 – helped by other people. Code: group / peer benefits?

46 /48 – one-to-one would be dull, but group can sometimes be distracting. code: group process

50 – external facilitators = good, not sticking to procedure of school, new things to show us. Code: group process? Novelty of facilitators

52 – can’t trust you fully. Code: trust / group process

58 – go out and tell other staff. Code: trust/ group process

65 – facilitators can take a joke, teachers can’t. code: group process, authority, facilitator style?

69 – **** made us behave properly, not ****. Code: need for boundaries/authority/ group process. Importance of balance!

80s – lots of reference to wanting more sessions, focused around which lessons they would be missing. Code: group as a soft option?

118 – missing lessons a bad thing, education important. Code: tension between soft option v importance of education.

120 – workbook, good, write stuff. Personal stuff.

122 – missed pages that were important. Code:

124 – less angry at my sister. Code: distal

188

People who inspire me. Code: making it personal/tailored. Content.

personal content = valuable.

changes?

131 – mindfulness. Think before you act. Code: content not entirely clear? Think before you act = clear take home message.

133 – my tiger is more calm. Code: distal benefits of group, metaphor/character important

144 – teacher c point, less angry, trying to earn it off. Code: distal benefits of group, thinking things through/less impulsive.

148 – don’t want to get into more trouble. Code: thinking before acting, thinking of consequence

154 – questionnaires – bit concerning. Code: content not relatable

158 – some of the questionnaires – bit weird. Content not relatable.

168 – half of them mean the same thing. Code: content not relatable, not clear?

174 – computer task, very frustrating. Code: measure effective?

190 – more games. Code: not taking group seriously? Content – engaging. Group as soft option?

199 – more snacks. Code: group as soft option? Group seen as fun?

203 – donut activity. Code: content = good, understanding purpose, metaphor = good.

209 – fifa. Code = make group engaging/interactive, group as soft option?

First reading of group 2 post focus group

4 – tiger = helpful. Code: content. Character/metaphor = good. Relatable.

6 – nothing unhelpful. Code: content = good.

10 – characters helpful, choosing the road. Code: clear messages, consequences, content, characters/metaphors = good.

12 – choice of paths to take. Code: content, clear, simple messages, consequences, choice

16 – choices. Code: choices

18 – 20 – group all good, not unhelpful. Code: content = good.

26 – make it longer, so I can miss it maths. Code: group as soft option?

29 – consequences don’t take away reward points. Code: not fair? Group organisation? Group process?

31 – yeh that wasn’t fair (consequence). Code: not fair? Group organisation.

38 – awkward one-to-one, relate to people your own age. Code: group process, importance of peers – relatable, group = comfortable.

40 – awkward on own, fear of being judged, not only you that goes through it. Code: judgement from teachers? Importance of peers, support from group – group process. Group = good.

44 – sharing your emotions. Code: peer support, group process

189

50 – group = comfortable. Code: feeling comfortable, safe? Group process? Boundaries?

56 – one to one, too much pressure. Code: importance of group process.

62/64 – good to have outside facilitators, teacher might bring up stuff, feel more comfortable. Code: trust, group boundaries, group process, safety in group? Feeling comfortable.

66 – teachers might have a vendetta/not like you, external facilitators don’t know you. Code: not judged.

68 – can trust you two. Code: trust

70 – teachers gossip. Code: trust, group boundaries, confidentiality.

72 – teachers might tell parents. Code: external facilitator important, trust/confidentiality

80 – male facilitator might be more helpful, can relate to how it feels. Code: relatable facilitator

84 – more banter with a man. Code: relatable facilitator

91 – time to think about it in the week (once a week). Code: in between session reflection? Consolidation?

97 – missing lessons. Code: group as a soft option?

102 – get more out of it (longer session time). Code: group = valuable?

110 – Thursdays, no. code; tension between group and lessons?

115, 116 – would not come if after school. Code: group not that valuable? Group organisation – not impede on liked activities?

133 – would like more sessions to avoid lessons they get in trouble in (less likely to get C points). Code: group as a soft option/positive alternative to lessons? Group as a way of staying out of trouble?

141 – talking to people getting more out of it. Code: need for more time talking, rather than just content? Personalised? Sharing important – group process. Group as a way of preventing anger spilling into lesson – proximal outcome of group.

149 – 155 mixed feelings on workbook – didn’t really do it properly. Code: organisation of group, relevance of content needs to be clear

156 – didn’t like writing, prefer talking. Code: importance of discussing/sharing, group process? Overloaded with content?

160 – use workbook to prompt thinking about group content. Code: workbook as reminder of content? Reinforces group messages?

170 – books help finish off goals. Code: reinforcing group messages? Goals = important? Clear messages?

172 /174 – not been in fight. Code: outcomes, distal benefits

176 – every day used to 178 /180/181– not 187 – thinking about GCSEs –

190

get in trouble. Code: outcomes, distal benefits

been on top 10 c points. Code: outcomes, distal benefits

code; thinking about consequences/goals, systemic influences (mum)

192 /193 – thinking about priorities, values. Code; outcomes, values

197 – they’re in year 9, picking options. Code – systemic influences on changes

201 – might’ve been a few, but not noticed. Code: outcomes – not noticed changes

205 – chose the right path. Code: thinking before acting, choices.

207 - getting blamed for things. Code: systemic influences on outcome – negative.

209 – unable to articulate why things have improved. Code: not sure what they’ve learnt/where to attribute outcomes?

213 – feeling victimised by teacher, not being listened to. Code: systemic influences on changes – negative.

215/219 – doing mindfulness thing by myself, making my own one. Code: skill development, outcomes – distal

224/226/232 – questionnaires stressful, irrelevant, offensive/deep questions. Code: content = disengaging, not relatable. Too invasive? Not pitched appropriately for level of risk?

234 – issues with questionnaire – could understand if someone had really bad anger issues. Code: inappropriate content, not pitched at appropriate level, disengaging

242 – take it out on a animal – doesn’t make sense at all. code: not relatable

250 - questionnaires were good. Code: content okay.

254 – computer task frustrating. Code: measure effective?

259 – call parents to celebrate child’s behaviour. Code: celebrating outcomes, need for systemic approval, importance of rewards

265 – boxing, physical things, hold your anger in and control it. Code: content not clear enough? Missing key messages? Need more interaction

271 / 273 – bring in an older person who has experienced anger. Code: importance of relatable facilitator

275/276/278 – not liking consequences, but rules are fine. Code: importance of safety/boundaries in group? Group shouldn’t be a place of punishment??

282 – proper anger management, obviously planned. Code: importance of feeling like the group is planned?

288 – more music. Code - different styles of presentation – interactive

292 – party – code: celebration, rewards

303 – maybe the cross roads….code: helpful content, choices, empowerment/responsibility?

191

Second reading of group 2 post focus group

4 – my anger is tiger, I should walk beside it, like the guy on the board. Code: character/metaphor important, relatable content – tiger in particular feels like anger?

10 – mindless zombie/wise warrior = helpful, choosing the right path. Code: character/metaphor, choices, empowerment/responsibility?

12 – choice of different paths to take, carry on, getting in trouble or calm down: Code: choices, consequence, responsibility?

16 – choose to go with my anger or stop it from escalating: code: choices, outcomes, responsibility

22 / 26 – two hours instead of one, miss maths. Code: group better option than school? Group soft option?

28 – consequences don’t take away your reward points. Code: group should not be about punishment.

31 – yeh that wasn’t fair. Code: fairness important.

38 – awkward if one to one. Code: group process, relate to peers

40/42 – going to be judged by teacher on own, group not just you that’s going through it. Code: group process, normalised by peers – we’re all in this, mutual support of peers, non judgement

44/50 – share your emotions (in a group) – code: group process = supportive, comfortable

56 – one to one, all attention on you. Code: group process – too intense one-to-one

60/62/64 – helped having external facilitator as teacher might bring things up, feel more comfortable. Code: group boundaries important, non-judgment, safety

66- fear of being judged by teachers who already carry knowledge about them. Code: separation from school/prior knowledge = important

68 – can trust you two. Code: trust/confidentiality

70 – teachers, gossip, risk being brought up in next lesson code: confidentiality, boundaries

72 – might tell parents. Code: confidentiality, fear of other

80 – male facilitator good – experienced it. Code:

84 – more banter with a man –

192

consequences, boundaries/safety/containment of group.

relatable facilitator, experts by experience

code: relatable facilitator

91 – week to think about the session. Code: between session reflection helpful

93/97 – reference to missing certain lessons. Code: group more enjoyable than lessons? Motivations behind attending the group?

100/102 – get more out of it. Code: group is valuable

114 – don’t want it after school, stuff to do. Code: priority of group compared to other commitments

131 – more sessions, missing sessions you are normally in trouble in. Code: ulterior motive for attendance (avoidance)

141 – talk about difficult experiences, sea rejecting: Code – benefits of group beyond content e.g. mutual support, off loading

146, 147 – skipped bits of workbook. Code: content not valued by facilitators? Not clear enough messages?

152/156 – didn’t like it, more writing. Better to say it than write it down. Code: workbook = burden? Talking and sharing mutual experiences?

160 – workbook helpful as prompt in the future regarding decisions: Code: ??

170 – finish off your goals (in the books). Code: importance of goals, beneficial effects of group outside of group

172/174 – not been in a fight – Code: distal effects of group, outcomes

178 – not been on top 10 c points – code: distal effects of group, outcomes

187/193– changed for GCSEs – code: systemic influences on change values/goals, priorities

197 – they’re in year 9 – more responsibilities, GCSEs around the corner: Code – systemic/maturational influences on change,

201 – not noticed changes. Code: no change, not noticed change

205 – chose the right path – Code: choices.

207 – ongoing frustrations when getting blamed for things by teachers.

213 – someone else laughing, me getting blamed. Code: labelled by school?

215 – making my own mindfulness up. Code: benefits lasting beyond group, distal benefits, skill development?

224/226/232 – questionnaires = stressful, offensive, questions too deep. Code: content unrelatable, you think I’m worse than I am?

234 – understand that question for someone with really bad anger issues: Code: unrelatable, labelling?

240 – take it out on animal, doesn’t make sense – code:

250 – questionnaires were good. Code: content

254 – computer task, frustrating.

193

unrelatable acceptable? Code: valid measure

259 – phone parents at end of group. Code: systemic acknowledgement of achievement / reward / celebrate progress

265 – boxing, physical. Hold in anger. Control it. Code: controlling anger, channelling anger, missing the point?

271 – facilitator to have experienced anger problems. Code: relatable facilitator

273 – guy talking about near miss . Code: relatable facilitator.

275 - 278 – get rid of consequences, not the rules. Code: not wanting punishment, group to be fair, boundaries and behaviour important – group process

282 – this is proper. This is obviously planned and stuff. Code: importance of planning, facilitators taking the group seriously

286 – music. Code: engaging, different presentation styles

292 – party at the end. Code: celebration

303 – maybe the crossroad. Code: choice

First reading of group 3 post focus group.

2 – didn’t want to participate at first, but that changed. Code: taking a while to settle in/warm up?

2 – more people to help them. Code: support – more wanted

8 /14– do less mindfulness. Code content, not engaging. Lacking skills? Inaccessible (too quiet).

10 – more of that donut thing. Code: content, engaging

16 – anger, something to get rid of and control. Code: control, getting rid. Missing the point?

24 – force people to attend so they realise it’s helpful. Code: taking a while to warm up to group? Initial barrier to engagement?

30 – characters helpful. Code: metaphor/character

34 – put other role models in (other than basketball). Code: role models – content, personalised, relatable

40 – express your feelings more, being taken out of the room if needed. Code: opportunity to offload, issues around group/confidentiality/trust/embarrassment?

46 – group – connect outside group, one2one=shy and not express yourself, know that they’re going to keep your

50 – additional benefits of group – people getting to know you as a person, rather than judging you. Code: building bonds with other people?

50 – misbehaving with friends (bad thing). Code: group dynamics/process, influence of peers (negative)

194

feelings and you’re going to keep theirs (note possible contradiction to previous point). Code: mutual trust/support, confidentiality, importance of peers modelling, less intense/embarrassing than one to one?52 – group changes people’s perceptions of individuals. Code: broader effects of group (unforeseen), social effects

58 – one-to-one = awkward, wouldn’t share. Group = hear other’s ideas, advice. Code: support/advice from group/peers, removes embarrassment factor

60 -at first, came to miss lessons, now its helping. Code: group as a soft option v group helping, slow burner

62 – teachers would think you are a bad person. Code: facilitator not bringing history. Not judging.

78 – wouldn’t be as open with a black man. Code: group safety, facilitator safety/boundary, relatable can be bad too?

82 – facilitator been through misbehaving – they can understand. Code: facilitator relatable

84 – session format (Weekly) allows time to think and do mindfulness. Code: importance of in between session reflection?

88 – wanting to time to talk about wider issues – life and the streets. Code: sharing wider systemic issues important – content not included? Content too narrow?

96 – reminder that we should control our anger. Code: control, frequency important, in between sessions a good reminder

104 – talking about wider issues that could get us out trouble would be good – problem solving. Code: content to be broader – more focus on systemic issues

112 – talk in more detail about wise warrior/mindless zombie, and role models. Code: content – lacking detail, pace too fast

116 – urge surfing – do more. Code: interactive activity good. Metaphor = good.

195

and problem solving.121 – longer = more likely to stick in your head. Code: ??

127 – more advice and help. Code; need for more time on content, more strategies

131 – period 5 and 6 – help us when we go home. Code: focus on lessons being missed? Transferability to different environments?

134 – thoughtful about when in day to time lessons. Code: organisation – what will make learning most transferable

138 – period 5 and 6 – think about it and then walk away Code: organisation and influence on transferability.

145 – workbook helps to think back to previous week. Code: value of content, reminders helpful to sustain learning

147 – good to take home as a reminder. Code: transferability of learning, need for reminders

157/160 – anger’s gone, calmed down more since I’ve been. Think and sorting out. Code: distal changes, capacity to think through, make choices

164/166 – not getting in trouble for getting angry. Can relax, calm myself down. Code: distal changes, keeping calm

168/170 – less c points, not in trouble for as big things. Code: distal changes

170 – teachers see you as misbehaving (Rather than anger). Code: teacher’s perceptions/preconceptions?

172 – characters, and thinking about future: Code: characters, future/consequences

180 – control. Code: control

184 – questionnaires, starting fires, bit weird. Code: questionnaires unrelatable.

186 – never knew people could do stuff like that Code: unrelatable

188 190– made me realise I knew people who would use weapons. How it harms others. Code: encouraging wider systemic thinking. Thinking about consequences to others

202 – happy to do questionnaires

204 – same

206 – a bit too long though. Code: questionnaires acceptable

208/209 – computer task – frustrating and stressful. Code: frustrating, valid measure

216 – didn’t really mind the task

196

224 – task made me feel worse. Code: valid measure, inaccessible (too frustrating)?

228 – tasks involving role models: Code: relatability, accessibility, role models, engaging/interactive

234 – games. Play board games and talk about feelings. Code: interactive content, making it fun??

240 – people who don’t get angry should come too. Code: content helpful/accessible to broader range of people.

252 – helps you to control yourself and teaches how to handle tough situations. Code: control (actions), content = strategies

260 – might not be able to trust teachers (depends on teacher257-258). Code: trust

273 – depends what subject you’re missing. Code: impact of group on schooling

278 – don’t mind two hours.

Second reading of group 3 post focus group.

2 – didn’t want to get involved at start; more people to help. Code: support important. Overcome initial barriers to engaging with more encouragement?

8 /10 – do less mindfulness, more donut thing. Code: content – engaging or disengaging.

14 – mindfulness, too quiet, never listen. Code: accessibility of mindfulness? Skill development (lack of)?

24 – force people to do it for a week. Code: barriers to initial engagement? Warming up to it?

30 – mindful zombie and wise warrior – helpful. Code: characters, metaphors = good content

32 – basketballer – have other role models. Code: role models, need material to be more relatable/personalised.

40 – express your feelings, taken out of room. Code: group process – sometimes need one-to-one? Valued opportunity to express feelings

46 – group = better as people to connect with outside. Less shy, show your feelings, keep each others feelings. Code: trust, confidentiality, normalisation of sharing feelings

50/52 – get to know your personality (not just that you’re angry). Code: broader, social benefits of group (unforeseen)

50 – with friends can misbehave (bad thing). Code; group process -influence of peers

58 – one to one would be awkward, people wouldn’t share. Code: intensity of one-to-one versus less pressure of group.

58 – use group’s ideas and advice. Code: group = more ideas

60 – first, just came to 62/64 – teachers would 66/68 – don’t mind who

197

miss lessons, now helping. Code: initial impressions - Soft option? Programme helpful

hold past information. Code: facilitators being open/non-judgemental

runs it. Code: ambivalence?

78 – black man facilitating – wouldn’t be as connected or open. Code: diversity/relatability issues?

82 – someone been through misbehaving. Code: relatability of facilitator/similarity

84 – frequency of sessions gave us time to think and do mindfulness. Code: organisation promotes time for reflection

88 – would like to discuss broader issues. Code: opportunity for more systemic discussions? Anger too narrow?

96 – Monday reminds us to control our anger for the rest of the week. Code: control, organisation – need for reminders

104 – longer sessions, talk about stuff that happened. Code: opportunity to discuss wider system issues, anger too narrow

106 – and how to deal with things in a better way. Code: more content on strategies = good.

112 – more sessions, to talk in more detail about characters and role models. Code – more time good, more opportunity for discussion/reflection

116 – more activities like surfing. – Code: metaphor, interactive activities = good

121 – more sessions, longer likely to stick in head. Code: need for greater volume to maintain learning.

127 – longer, more learning, more advice. Code: longer = greater opportunity for more advice.

131 – timing at end of day – in mind when we go home. Code: organisation – out of sight out of mind? materials/processes to remind/increase salience of messages = helpful

145 -workbook good as reminder. Code: materials/processes to remind/increase salience of messages = helpful

147 – take home and use it as a reminder. Code: need or prompting, increasing salience?

156/158 – anger’s calmed down since coming to group – its just something there, don’t really need to take it out on other people, sort it out with them. Code: sitting with! Making choices (rather than impulsive responses)

164/166 – not getting in trouble in class for being angry – can relax and calm myself down. Code: emotion regulation skill – core ACT skills code??

168/170 – less c points, anger makes things worse, teachers see it as misbehaving. Code: consequences, not understood by teachers?

172 – wise warrior, mindfulness, thinking about future. Code: characters/salience, consequences/values

198

180 – not in trouble as much, controlled myself. Code: control (over actions - ACT)?

184 – questionnaires, interesting but weird. Code: not relatable

186 – never knew people could do stuff like that. Code: not relatable.

188 – knew people who would hold weapons. Code: encouraging wider systemic thinking?

190 – it harms other people. Code: consequences

200 – didn’t understand how someone could feel that when angry. Code: not relatable

202 – happy to do them. Code: questionnaires -fine.

208/209 – computer task frustrating and stressful. Code: valid test.

226 – food. Code: group = social, fun?

228 – tasks and role models. Code: relatable, interactive

230 – games related to controlling self. Code: control (Actions), interactive, fun

234 – board games and talk about our feelings. Code: emotional expression, interactive, fun

252 – recommend group, helps you to control yourself and teaches ways to handle yourself. Code: control, strategies

256-259 – honesty depends on teacher. Code: facilitator and prior relationship important.

260 – might not be able to trust teachers. Code: trust

272 – 2 hour sessions – depends on what missing. Code; conflict between missing lessons and attending group

199

Appendix 8b - Reference Document 2

Code identification: Following “rough notes” in document one, these were condensed into the codes below. Codes that are highlighted in groups 2 and 3 are additional codes to those already established in the previous transcripts. 16 th August 2016

Group 1, post focus group. Summary of identified codes:

Control Keeping calm / relaxed HelpfulBoring Characters ConsequencesMindfulness New friends Interacting with people

from other backgroundsGroup support Group distraction New ideasTrust Facilitator style Lessons missed – goodFrequency Duration Lessons missed – badUnhelpful Valued content Less angry/negative

consequences of angerThinking before acting/less impulsive

Metaphor Engaging

Not answering back Un-relatable RelatableInteractive Fun DisengagingRepetitive Skill development Confidentiality Influence of peers Authority Easy optionSchool v group tension Personalised content Making choicesGenerating concern/offence

Ambivalence Lack of clarity around purpose

Boundaries Clear messages Valid measure

Group 2, post focus group. Summary of identified codes. Highlighted = additional to group 1.

Character Metaphor RelatableClear messages Consequences ChoicesEasy option Fairness ComfortableJudgement Safety HelpfulGroup support Support from peers BoundariesIntense/pressure Trust ConfidentialityFacilitator relatable Between-session reflection Valued contentSchool v group tension Group not valued Talking time valuedAdditional re-enforcers of group content/messages to increase salience

Goals/values Less angry/negative consequences of anger

Systemic influences on changes

No change Thinking before acting

Lack of awareness of cause of changes

Skill development Un-relatable

Generating concern/offence

Disengaging Valid measure

200

Rewards Celebration Need for systemic approval

Lack of clarity around purpose

Interactive No punishment

Group planning important

Empowerment/responsibility Non-judgement

Normalisation by peers Priority of group Content not valued by facilitators

Off-loading Maturational influences on change

Blame

Control

Group 3, post focus group. Summary of identified codes. Highlighted = additional to groups 1 and 2.

Time to settle/warm up to group

More support wanted Lack of skills

Disengaging Engaging Metaphor Character Personalised content Relatable Role models Off-loading ConfidentialityTrust Embarrassment Group supportSupport from peers Intense/pressure People getting to know

youNon-judgement Influence of peers –

negativeChanging others perceptions

Easy option Safety BoundariesRelatable facilitator - negative

Relatable facilitator Between-session reflection

Content to include wider systemic issues

Control Frequency

Additional re-enforcers of group content/messages to increase salience

More detail Pace too fast/need more time

Interactive More strategies Transferability to different environments

School v group tension Valued content Thinking before actingChoices Keeping calm/relaxed ConsequencesThinking about future Less angry/negative

consequences of angerJudgement

Teacher preconceptions Un-relatable Consequences – to othersValid measure Helpful Fun Normalisation by peers Ambivalence Talking time valuedDuration Sitting with difficult

feelingsEmotion regulation

Condensed list of codesTerm listed above Condensed term Code

201

number

Control Control 1.Boring, repetitive, engaging, disengaging, generating concern/offence

Engaging/Disengaging 2.

Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation

Skill development/Lack of skills 3.

Group support, new ideas, support from peers, comfortable, embarrassment

Group support and help; benefits of group

4.

Trust, confidentiality Trust/Confidentiality 5.Frequency, duration, pace too fast/need more time

Pacing of group 6.

Unhelpful, helpful Helpfulness 7.Thinking before acting/less impulsive, not answering back

Thinking before acting 8.

Interactive, fun Interactive/fun 9.Influence of peers, influence of peers – negative, group distraction, normalisation by peers

Influence of peers 10.

School v group tension, lessons missed – good, lessons missed – bad, priority of group

Group priority (over school and other commitments)

11.

Boundaries, safety Boundaries/safety 12.Keeping calm/relaxed Keeping calm/relaxed 13.Characters, metaphor Character/metaphor 14.New friends New friends 15.Facilitator style, authority Facilitator style 16.Valued content, group planning important, group not valued

Valued/not valued 17.

Un-relatable, relatable Relatability of content 18.Personalised content Personalisation 19.Ambivalence Ambivalence 20.Clear messages, lack of clarity around purpose

Importance of clear, simple messages 21.

Consequences, consequences – to others

Thinking about consequences 22.

Interacting with people from other backgrounds, people getting to know you, changing others perceptions

Broader benefits of group 23.

202

Less angry/negative consequences of anger, no change, lack of awareness of change

Changes from group – proximal and distal

24.

Easy option Group as easy option 25.Making choices, choices Choices 26.Valid measure Valid measure 27.Judgement, non-judgement Judgement/Non-judgement 28.Intense/pressure, embarrassment

Intense/pressure 29.

Facilitator relatable, relatable facilitator - negative

Relatability of facilitator 30.

Additional re-enforcers of group content/messages to increase salience, between-session reflection

Reminders/re-enforcers 31.

Systemic influences on changes, maturational influences on change

External influences on change (maturation, systemic)

32.

Lack of awareness of cause of changes

Unclear why change has occurred 33.

Rewards, celebration, need for systemic approval

Rewards/celebration/acknowledgement 34.

Off-loading, talking time valued

Talking/expressing 35.

Fairness, no punishment Punishment/behaviour management 36.Goals/values, thinking about future

Consideration of things that are important

37.

Empowerment/responsibility Empowerment/responsibility 38.Content not valued by facilitators

Content not valued by facilitators 39.

Time to settle/warm up to group

Initial barriers to engagement 40.

Role models Role models 41.Content to include wider systemic issues, more detail, more strategies

Content too narrow 42.

Teacher preconceptions, blame

Teacher’s perceptions 43.

More support wanted More support from facilitator wanted 44.Transferability to different environments

Transferability to different environments

45.

203

Appendix 8c – Reference Document 3Theme Generation 22nd August 2016 - Supervisory discussion

Ideas for themes Ideas for themes: group content (personal relevance, accessibility, clear messages), group process (facilitator style, peers, boundaries/safety, confidentiality/trust), group organisation (workbook, lessons, facilitators), outcomes (think before act, broader skill development, consequences), choices, control, systemic influences on change

6 c’s Confidentiality, Content, Control, (group process – peers, facilitator style), Change, Choices, Consequences, Contextual factors, Communication23rd August 2016 - Further ideas for themesIdeas for themes: group content (relatability, engaging, clear messages), group process (facilitator style, peers, boundaries/safety, confidentiality/trust), group organisation (workbook, lessons, facilitators), outcomes (think before act, broader skill development, consequences), choices, control, systemic influences on change, positive experiences v negative experiences.

Overarching themes – content versus process; individual versus contextual factors

o Contento Culture of group – confidentiality, group process, etco Contextual considerationso Changes – choices, control, consequences

Initial attempts at organising codes into themes – see theme map 1, appendix 8dTerm listed above Condensed term Code

numberTheme

Control Control 46. ChangesBoring, repetitive, engaging, disengaging, generating concern/offence

Engaging/Disengaging 47. Content

Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation

Skill development/Lack of skills

48. Changes

Group support, new ideas, support from peers, comfortable, embarrassment

Group support and help; benefits of group

49. Culture of group

Trust, confidentiality Trust/Confidentiality 50. Culture of groupFrequency, duration, pace too fast/need more time

Pacing of group 51. Contextual considerations

Unhelpful, helpful Helpfulness 52.Thinking before acting/less impulsive, not answering back

Thinking before acting 53. Changes

Interactive, fun Interactive/fun 54. Content/ Culture of group

Influence of peers, influence of peers – negative, group

Influence of peers 55. Culture of group

204

distraction, normalisation by peersSchool v group tension, lessons missed – good, lessons missed – bad, priority of group

Group priority (over school and other commitments)

56. Contextual considerations

Boundaries, safety Boundaries/safety 57. Culture of groupKeeping calm/relaxed Keeping calm/relaxed 58. ChangesCharacters, metaphor Character/metaphor 59. ContentNew friends New friends 60. Changes / Culture

of groupFacilitator style, authority Facilitator style 61. Culture of groupValued content, group planning important, group not valued

Valued/not valued 62. Content

Un-relatable, relatable Relatability of content 63. ContentPersonalised content Personalisation 64. ContentAmbivalence Ambivalence 65.Clear messages, lack of clarity around purpose

Importance of clear, simple messages

66. Content

Consequences, consequences – to others

Thinking about consequences

67. Changes

Interacting with people from other backgrounds, people getting to know you, changing others perceptions

Broader benefits of group

68. Changes

Less angry/negative consequences of anger, no change, lack of awareness of change

Changes from group – proximal and distal

69. Changes

Easy option Group as easy option 70. Contextual considerations / Culture of group

Making choices, choices Choices 71. ChangesValid measure Valid measure 72.Judgement, non-judgement Judgement/Non-

judgement73. Culture of group /

Contextual considerations

Intense/pressure, embarrassment

Intense/pressure 74. Culture of group

Facilitator relatable, relatable facilitator - negative

Relatability of facilitator 75. Culture of group

Additional re-enforcers of group content/messages to increase salience, between-session reflection

Reminders/re-enforcers 76. Contextual considerations

205

Systemic influences on changes, maturational influences on change

External influences on change (maturation, systemic)

77. Contextual considerations / Change

Lack of awareness of cause of changes

Unclear why change has occurred

78. Change

Rewards, celebration, need for systemic approval

Rewards/celebration/acknowledgement

79. Content / Culture of group

Off-loading, talking time valued

Talking/expressing 80. Culture of group / Content

Fairness, no punishment Punishment/behaviour management

81. Culture of group / Contextual factors

Goals/values, thinking about future

Consideration of things that are important

82. Change / Contextual considerations/ Content

Empowerment / responsibility

Empowerment / responsibility

83. Change

Content not valued by facilitators

Content not valued by facilitators

84.

Time to settle/warm up to group

Initial barriers to engagement

85. Culture of group

Role models Role models 86. Culture of group / Content

Content to include wider systemic issues, more detail, more strategies

Content too narrow 87. Content / Contextual considerations

Teacher preconceptions, blame

Teacher’s perceptions 88. Contextual considerations

More support wanted More support from facilitator wanted

89. Culture of group

Transferability to different environments

Transferability to different environments

90. Contextual considerations

Codes without themes: Helpfulness – important, needs to be included, links with all 4 themes

identified above Valid measure – less important. Separate point, only really refers to computer

task? Content not valued by facilitators – less important, rare occurrence. Ambivalence – fairly rare.

Comments on themes - see theme map 1, appendix 8d Changes and Content = good. On initial viewing, appear to have internal

homogeneity. Some links with other themes. Culture = too heterogenous. Context = too heterogenous and too many links with other themes.

206

Resultant changes Culture subdivided: Culture of group – structural and content factors; Culture

of group – interpersonal factors Context subdivided: Contextual considerations – intra and interpersonal;

Contextual considerations – practical Helpfulness removed as a code as this was too broad and covering all themes,

and largely covered by existing codes, particularly valued/not valued (17) Interactive/fun (9) reviewed and re-categorised as referring only to content, as

this was largely the case and in other examples it was captured by other codes. This allowed greater internal homogeneity and external heterogeneity.

Role models (41) re-categorised to only include reference to role models in the content of the group. Reference to wanting facilitators who have had similar experiences has been solely included under “relatable facilitator”. Role models now categorised under content.

Rewards (34) redefined as “external acknowledgement of achievement”. Categorised under “contextual considerations: intra and interpersonal”

Overlap between 32 (external influences on change) and 37 (consideration of things that are important). 37 now includes only reference to goals, and is classified under “content”, 32 has incorporated “thinking about the future” and is classified under context: intra and interpersonal, and “change”.

New themes: - see theme map 2, appendix 8e Culture of group

Subthemes – Culture of group: Structural factorsCulture of group: Interpersonal

Contextual considerationsSubthemes - Contextual considerations: Intra and interpersonal

Contextual considerations: Practical Changes Content

Term listed above Condensed term Code number

Theme

Control Control 1. ChangesBoring, repetitive, engaging, disengaging, generating concern/offence

Engaging/Disengaging 2. Content

Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation

Skill development/Lack of skills

3. Changes

Group support, new Group support and help; 4. Culture of

207

ideas, support from peers, comfortable, embarrassment

benefits of group group: Interpersonal

Trust, confidentiality Trust/Confidentiality 5. Culture of group: Structural factors

Frequency, duration, pace too fast/need more time

Pacing of group 6. Contextual considerations: Practical

Unhelpful, helpful Helpfulness 7. Thinking before acting/less impulsive, not answering back

Thinking before acting 8. Changes

Interactive, fun Interactive/fun 9. Content Influence of peers, influence of peers – negative, group distraction, normalisation by peers

Influence of peers 10. Culture of group: Interpersonal

School v group tension, lessons missed – good, lessons missed – bad, priority of group

Group priority (over school and other commitments)

11. Contextual considerations: Practical

Boundaries, safety Boundaries/safety 12. Culture of group: Structural factors

Keeping calm/relaxed Keeping calm/relaxed 13. ChangesCharacters, metaphor Character/metaphor 14. ContentNew friends New friends 15. Changes /

Culture of group: Interpersonal

Facilitator style, authority

Facilitator style 16. Culture of group: Interpersonal

Valued content, group planning important, group not valued

Valued/not valued 17. Content

Un-relatable, relatable Relatability of content 18. ContentPersonalised content Personalisation 19. ContentAmbivalence Ambivalence 20.Clear messages, lack of clarity around purpose

Importance of clear, simple messages

21. Content

Consequences, consequences – to others

Thinking about consequences

22. Changes

208

Interacting with people from other backgrounds, people getting to know you, changing others perceptions

Broader benefits of group 23. Changes

Less angry/negative consequences of anger, no change, lack of awareness of change

Changes from group – proximal and distal

24. Changes

Easy option Group as easy option 25. Contextual considerations: Practical / Culture of group: Interpersonal

Making choices, choices Choices 26. ChangesValid measure Valid measure 27.Judgement, non-judgement

Judgement/Non-judgement 28. Culture of group: Interpersonal / Contextual considerations: Intra and interpersonal

Intense/pressure, embarrassment

Intense/pressure 29. Culture of group: Structural

Facilitator relatable, relatable facilitator – negative

Relatability of facilitator 30. Culture of group: Interpersonal

Additional re-enforcers of group content/messages to increase salience, between-session reflection

Reminders/re-enforcers 31. Contextual considerations: Practical

Systemic influences on changes, maturational influences on change, thinking about future

External influences on change (maturation, systemic)

32. Contextual considerations: Intra and interpersonal / Change

Lack of awareness of cause of changes

Unclear why change has occurred

33. Change

Need for systemic approval

External acknowledgement of achievement

34. Contextual considerations: Intra and interpersonal

209

Off-loading, talking time valued

Talking/expressing 35. Culture of group: Interpersonal / Content

Fairness, no punishment Punishment/behaviour management

36. Culture of group: Structural / Contextual considerations: Practical

Goals Goals 37. ContentEmpowerment / responsibility

Empowerment / responsibility

38. Change

Content not valued by facilitators

Content not valued by facilitators

39.

Time to settle/warm up to group

Initial barriers to engagement

40. Culture of group: Structural

Role models Role models 41. ContentContent to include wider systemic issues, more detail, more strategies

Content too narrow 42. Content

Teacher preconceptions, blame

Teacher’s perceptions 43. Contextual considerations: Intra and interpersonal

More support wanted More support from facilitator wanted

44. Culture of group: Interpersonal

Transferability to different environments

Transferability to different environments

45. Contextual considerations: Practical

5 th September 2016 - See theme map 3, appendix 8f

Review of above themes for internal homogeneity and external heterogeneity. Punishment/behaviour management (code 36). Transcripts reviewed and it

was felt that this was adequately covered by Culture: Structural and did not need additional classification under Context: Practical.

External influences on change reclassified solely under Context: Inter/Intrapersonal as, after reviewing transcripts and themes, it was felt that the change category referred largely to what changes had occurred, as opposed to influences on changes.

Judgement/non judgement was reclassified to bridge the two subcategories of culture as, after reviewing transcripts, it was deemed to refer more to the way the group was set up as opposed to the context in which the group occurred.

210

Easy option code occurs solely with interactive/fun code, and pacing / group priority codes. After review of transcripts, it was felt that “group as an easy option” when referring to missed lessons etc could be adequately captured by the group priority code (11). Code 25 was thus used only to refer to content. Easy option moved to theme of “content” only. Group priority code renamed to “group v other options”

“New friends” was re-examined. Rather than bridging two themes, extracts were recoded into either “broader benefits of group” (under change theme) and /or “new friends”, which was moved to solely reside in “Culture of group: Interpersonal”.

Talking/expressing moved solely to “Culture of group: Interpersonal”.

11 th December 2016 – See final theme maps in main body of paperReviewed transcripts again after long break as a final check on coding and themes.

A couple of minor re-codes were made on transcripts (i.e. where a code had been missed, or where one was given which was not required as was covered by other codes)

“Intense/pressure” code was changed to “Intense/awkward” as it felt this would more accurately encapsulate the comments

Code 24 name was changed as this overlapped with the overall theme title and did not really highlight what it was referring to. Changed to “anger-related incidents”.

No change code was created to “mop up” the remainder of the previous code 24

NB: Table below incorporates 5th September and 11th December changes

Term listed above Condensed term Code number

Freq.

Theme

Control Control 1. 8 ChangesBoring, repetitive, engaging, disengaging, generating concern/offence

Engaging/Disengaging 2. 15 Content

Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation

Skill development/Lack of skills

3. 7 Changes

Group support, new ideas, support from peers, comfortable, embarrassment

Group support and help; benefits of group

4. 9 Culture of group: Interpersonal

Trust, confidentiality Trust/Confidentiality 5. 9 Culture of group:

211

Structural factors

Frequency, duration, pace too fast/need more time

Pacing of group 6. 17 Contextual considerations: Practical

Unhelpful, helpful Helpfulness 7. Thinking before acting/less impulsive, not answering back

Thinking before acting 8. 4 Changes

Interactive, fun Interactive/fun 9. 13 Content Influence of peers, influence of peers – negative, group distraction, normalisation by peers

Influence of peers 10. 5 Culture of group: Interpersonal

School v group tension, lessons missed – good, lessons missed – bad, priority of group

Group v other options 11. 18 Contextual considerations: Practical

Boundaries, safety Boundaries/safety 12. 7 Culture of group: Structural factors

Keeping calm/relaxed Keeping calm/relaxed 13. 3 ChangesCharacters, metaphor Character/metaphor 14. 9 ContentNew friends New friends 15. 2 Culture of

group: Interpersonal

Facilitator style, authority Facilitator style 16. 8 Culture of group: Interpersonal

Valued content, group planning important, group not valued

Valued/not valued 17. 28 Content

Un-relatable, relatable Relatability of content 18. 11 ContentPersonalised content Personalisation 19. 5 ContentAmbivalence Ambivalence 20. 3Clear messages, lack of clarity around purpose

Importance of clear, simple messages

21. 5 Content

Consequences, consequences – to others

Thinking about consequences

22. 7 Changes

Interacting with people from other backgrounds, people getting to know you, changing others perceptions

Broader benefits of group

23. 6 Changes

Less angry/negative Changes from group – 24. 13 Changes

212

consequences of anger proximal and distalAnger-related incidents

Easy option Group as easy option 25. 4 ContentMaking choices, choices Choices 26. 7 ChangesValid measure Valid measure 27. 4Judgement, non-judgement

Judgement/Non-judgement

28. 3 Culture of group: Interpersonal / Culture of group: Structural

Intense/pressure, embarrassment

Intense/pressureIntense/awkward

29. 5 Culture of group: Structural

Facilitator relatable, relatable facilitator – negative

Relatability of facilitator 30. 8 Culture of group: Interpersonal

Additional re-enforcers of group content/messages to increase salience, between-session reflection

Reminders/re-enforcers 31. 8 Contextual considerations: Practical

Systemic influences on changes, maturational influences on change, thinking about future

External influences on change (maturation, systemic)

32. 5 Contextual considerations: Intra and interpersonal

Lack of awareness of cause of changes

Unclear why change has occurred

33. 2 Change

Need for systemic approval

External acknowledgement of achievement

34. 1 Contextual considerations: Intra and interpersonal

Off-loading, talking time valued

Talking/expressing 35. 8 Culture of group: Interpersonal

Fairness, no punishment Punishment/behaviour management

36. 6 Culture of group: Structural

Goals Goals 37. 2 ContentEmpowerment / responsibility

Empowerment / responsibility

38. 4 Change

Content not valued by facilitators

Content not valued by facilitators

39. 1

Time to settle/warm up to group

Initial barriers to engagement

40. 2 Culture of group: Structural

Role models Role models 41. 4 ContentContent to include wider Content too narrow 42. 3 Content

213

systemic issues, more detail, more strategiesTeacher preconceptions, blame

Teacher’s perceptions 43. 7 Contextual considerations: Intra and interpersonal

More support wanted More support from facilitator wanted

44. 2 Culture of group: Interpersonal

Transferability to different environments

Transferability to different environments

45. 3 Contextual considerations: Practical

No change, lack of awareness of change

No change 46. 1 Changes

214

Appendix 8d – Theme Map 1

215

Appendix 8e – Theme Map 2

216

Appendix 8f – Theme Map 3

217

Appendix 8g – Examples of Coded Extracts22

Pseudo-nym

Time Content First reading codes Second reading codes Draft code

Recoding after theme generation

Final codes after 11th Dec changes

Laura 4:10 Okay. Okay, we’ll go to Freddie next.Freddie 4:11 Umm, what I found helpful was, ummm,

the…the warrior and the mindless zombie (Laura: Mmhmm). Because, umm, if you…there’s like a (inaudible) about the mindless zombie...I mean not mindless zombie (Laura: Mmhmm), if you…the wise warrior, and, the mindless zombie, was it…it can help umm in which side you choose. You can choose like the road (Laura: Mmhmm). Yeh.

10 – characters helpful, choosing the road. Code: clear messages, consequences, content, characters/metaphors = good.

10 – mindless zombie/wise warrior = helpful, choosing the right path. Code: character/metaphor, choices, empowerment/responsibility?

7, 14, 26, 38, 21

17, 14, 26, 38, 21

17, 14, 26, 38, 21

Laura 4:40 So the two characters and choosing the road was helpful for you, yeh?Fantastic, thank you. Yes Gabriel?

Gabriel 4:46 What I learnt is that, what’s it called, when I’m angry I have a choice of different paths to take (Laura: Mmhmm)…whether to….carry on and get myself in more trouble, or calm down.

12 – choice of paths to take. Code: content, clear, simple messages, consequences, choice

12 – choice of different paths to take, carry on, getting in trouble or calm down: Code: choices, consequence, responsibility?

26, 21, 38, 22

26, 21, 38, 22

26, 21, 38, 22

Laura 4:56 Okay lovely, so thinking about the paths was helpful and how to choose what to do? (Gabriel Mmhmm) Great, okay.

Farouk 5:03 I was going to say that as well… 26, 38 26, 38Laura 5:05 That’s okay, you say it however you like to

22 All names in extracts are pseudonyms.

218

say it, it doesn’t matter if it’s already been said.

Farouk 5:08 Oh okay. So (inaudible)….I chose the path because, I can choose to…go with my anger, or stop it…from….from from….oh what’s the word? (Gabriel: Escalating). Yeh, stop it from escalating.

16 – choices. Code: choices

16 – choose to go with my anger or stop it from escalating: code: choices, outcomes, responsibility

26, 38

219

Pseudo-nym

Time Content First reading codes Second reading codes Draft code

Recoding after theme generation

Final codes after 11th Dec changes

Laura 13:40 […] Okay, umm, and what about the format of the groups? So obviously we had umm weekly sessions, with in-between practices with Poppy when you could get to them. How did you find that, was that about right (Callum: Yeh), not enough? Too much? (Callum: Yeh) You thought that was okay, Callum? Yeh? What about the rest of you?

Callum 14:17 Umm…cause, I think it’s good, ‘cause it gave us, like, time to think. And time to do the mindfulness session with Poppy.

84 – session format (Weekly) allows time to think and do mindfulness. Code: importance of in between session reflection?

84 – frequency of sessions gave us time to think and do mindfulness. Code: organisation promotes time for reflection

31, 6 31, 6 31, 6

Laura 14:25 Yep. So you liked having that time to practise it as well, yeh?

Callum 14:30 Yeh.Laura 14:30 Good. Finley?Finley 14:31 I think, yeh, you know on Monday’s with Poppy…

umm…’cause in *** we talk about a lot, like, about things that happen (Yep). We…we should do that, like, on Mondays…and then, talk about umm…umm, life and…and the streets and all that.

88 – wanting to time to talk about wider issues – life and the streets. Code: sharing wider systemic issues important – content not included? Content too narrow?

88 – would like to discuss broader issues. Code: opportunity for more systemic discussions? Anger too narrow?

42 42 42

Laura 14:50 Okay, so the sessions that you had with Poppy, on the Mondays, you would like to be able to just talk a little bit more about (Finley: Yeh) some of the stuff that’s going on? Yeh? Okay. Do you think you would’ve liked to have done that in the group as well? Talk a bit more about

220

what’s going on in your life?Finley 15:04 Mmhmm.Laura 15:05 Yeh? Okay, thanks Finley. Lemar, Fazal, would you like

to comment on, umm, how you found having the sessions weekly?

1, 31 1, 31

Lemar 15:24 Helpful in a way.Laura 15:26 Helpful in a way?Lemar 15:27 Yeh.Laura 15:28 Okay. In what way?Lemar 15:35 Umm, because, if we…because we have it on Monday…so

then yeh….it gives us, umm…it reminds us that we’re coming here after the weekend, because sometimes we…for the rest of the week, we should control our anger. And umm…’cause…yeh.

96 – reminder that we should control our anger. Code: control, frequency important, in between sessions a good reminder

96 – Monday reminds us to control our anger for the rest of the week. Code: control, organisation – need for reminders

1, 31

Pseudo-nym

Time Content First reading codes

Second reading codes

Draft code

Recoding after theme generation

Final codes after 11th

221

Dec changes

Laura 8.49 Okay. So it’s nice not to have all that pressure on you? (Gabriel: Mmhmm, yeh). Okay. Okay, and how did you find it…and again please be honest about this (just checking that’s recording, its fine). So obviously Jessica and I, umm, don’t work in the school…so we’ve come from outside the school to come into the group to run it…how did you find it having people from outside the school coming into the group to run it?

Gabriel 9:10 Easy peasy (laughter), lemon squeezy. Laura 9:15 Yes Gabriel?Gabriel 9:16 Oh what’s it called, yeh I think it helped, ‘cause it’s not someone…

it’s someone different from the school, someone that comes from another school

60/62/64 – helped having external facilitator as teacher might bring things up, feel more comfortable. Code: group boundaries important, non-judgment, safety

12, 5, 43

12, 5, 43 12, 5, 43

Taylor 9:22 Someone that knows you…Gabriel 9:23 Yeh because, like, yeh say it was another teacher in the school

(Laura: Mmhmm). You’ll be seeing that teacher every day (Laura: Mmhmm), and if you do something wrong, out of anger, the teacher might bring it up.

62/64 – good to have outside facilitators, teacher might bring up stuff, feel more comfortable. Code: trust, group boundaries, group process, safety in group? Feeling comfortable.

Laura 9:31 Right, okay.Gabriel 9:33 But if it was a teacher, that, what’s it called, doesn’t work in the

school, you only see them like only in that session, and you feel more comfortable, talking to them, and telling them…stuff, yeh.

Laura 9:41 Okay, good, thank you, Taylor?Taylor 9:44 Also, if it’s a teacher yeh, like, say you don’t actually like the teacher

(Freddie: Yeh). Or, if someone… a teacher, that you don’t really get 66 – teachers might have a

66- fear of being judged by teachers

43, 28 43, 28 43, 28

222

along with. (Laura: Mmhmm). Yeh, like, you’d be in a one-to-one with them, and like say you do one thing wrong, like, they know…they know who you are, so they’d be like ‘I’ve got things on you. Do anything bad you’re dead.’ But then, with, having like come outside the school, don’t really know you, so it’s like a new thing (Laura: Mmhmm)…yeh.

vendetta/not like you, external facilitators don’t know you. Code: not judged.

who already carry knowledge about them. Code: separation from school/prior knowledge = important

Laura 10:10 Okay, thank you Taylor. Yes, Farouk?Farouk 10:12 Well, you can trust you two, you two…because, yeh…yeh that’s all.

Yeh, that’s all.68 – can trust you two. Code: trust

68 – can trust you two. Code: trust/confidentiality

5 5 5

Laura 10:20 So able to trust someone? (Farouk: Yeh) Okay, lovely. Freddie did you want to add anything on that? (Freddie: No). Okay. Gabriel?

Gabriel 10:28 Another reason why I prefer teachers from another school because like, teachers, they gossip. (Laura: Okay). Cause like, you don’t want...don’t want them in the staff room, gossiping about your business (Laura: Okay) and…and what’s it called, another teacher just brings it up in the next lesson.

70 – teachers gossip. Code: trust, group boundaries, confidentiality.

70 – teachers, gossip, risk being brought up in next lesson code: confidentiality, boundaries

5, 12 5, 12 5, 12

Laura 10:43 So the confidentiality part of it (Gabriel: Mmhmm) is quite important. Yes, Freddie?

Freddie 10:47 Like, umm, if…if, if your…if one of your teachers were doing it with you…and if they tell your parents, umm, how badly…how badly you’ve behaved. Then...then…. (laughter; Laura instructs boys to settle down). Then…then umm...they might, then they might, they might umm, have a meeting.

72 – teachers might tell parents. Code: external facilitator important, trust/confidentiality

72 – might tell parents. Code: confidentiality, fear of other consequences, boundaries/safety/containment of group.

5, 12 5, 12 5, 12

Laura 11:10 Right okay. So you’d be worried about it going back to parents, if it was teachers? Yeh? Okay, that’s a helpful point. Please remember the group rules, about being respectful.

Gabriel 11:17 We broke them already miss.Laura 11:19 Errm, that was a really helpful point, thank you. And was there…

would you prefer, umm, anyone else different facilitating the group? 30 30

223

Maybe a man facilitating, would that make it any better (Farouk: Yeah) or any worse?

Farouk 11:31 Like, they have experienced it…experienced this anger before, so like (Freddie: Communicate) Yeh, tell us… (another voice, inaudible)

Laura 11:40 Okay, so would that be about it being a man, or being someone who’s experienced anger before?

Taylor 11:45 Everyone experiences angerLaura 11:46 Well, yeh, good point.Taylor 11:48 But…(inaudible). I know what you’re saying, because like, if it was a

man yeh, we could be like “yeh yeh” and he could be like, “yeh I understand what happens”, ‘cause obviously he’s a male (Laura: Mmhmm) so he like, the same kinda anger thing happens

80 – male facilitator might be more helpful, can relate to how it feels. Code: relatable facilitator

80 – male facilitator good – experienced it. Code: relatable facilitator, experts by experience

30

Laura 11:57 Right, so that might be helpful, would it?Taylor 11:59 Yeh

224

Appendix 9 – Ethical Approval

225

Appendix 10 – Information and Consent Forms

226

227

228

229

230

Appendix 11 – Normality AnalysesDescriptive Statistics

N Minimum Maximum Mean Std. Deviation Skewness Kurtosis

Statistic Statistic Statistic Statistic Statistic Statistic Std. Error Statistic Std. Error

AARS instrumental anger, pre 17 21 49 28.76 9.801 1.267 .550 .055 1.063

AARS reactive anger, pre 17 10 32 19.65 5.852 .360 .550 -.250 1.063

AARS anger control, pre 17 23 48 31.88 7.381 1.041 .550 -.046 1.063

AARS total anger, pre 17 53 120 81.53 19.790 .369 .550 -.705 1.063

SDQ emotional symptoms, pre 17 .00 5.00 1.9559 1.42586 .681 .550 -.201 1.063

SDQ conduct problems, pre 17 2.00 7.00 3.5882 1.76985 .793 .550 -.577 1.063

SDQ hyperactivity/inattention, pre 17 3.00 7.00 4.5882 1.27764 .287 .550 -1.064 1.063

SDQ peer relationship problems, pre 17 .00 5.00 2.0588 1.34493 .579 .550 -.325 1.063

SDQ internalising difficulties, pre 17 1.00 8.00 4.0147 1.93744 .267 .550 -.100 1.063

SDQ externalising difficulties, pre 17 5.00 13.00 8.1765 2.42990 .271 .550 -.892 1.063

SDQ total difficulties, pre 17 6.00 17.00 12.1912 3.39062 -.555 .550 -.805 1.063

SDQ prosocial behaviour, pre 17 3.00 10.00 6.2941 2.20127 .174 .550 -1.160 1.063

Mean MAAS-A score, pre 17 3.43 5.64 3.9568 .62152 1.639 .550 2.309 1.063

AARS instrumental anger, post 15 21 35 25.87 4.926 1.114 .580 -.437 1.121

AARS reactive anger, post 15 10 26 18.07 4.803 .185 .580 -.957 1.121

AARS anger control, post 15 22 40 33.20 5.943 -.803 .580 -.405 1.121

AARS total anger, post 15 62 102 75.73 11.787 1.006 .580 .247 1.121

SDQ emotional symptoms, post 15 .00 5.00 2.1000 1.79483 .764 .580 -.879 1.121

SDQ conduct problems, post 15 .00 7.00 3.4667 1.72654 .113 .580 .393 1.121

SDQ hyperactivity/inattention, post 15 1.00 7.50 4.3667 1.81725 -.010 .580 -.449 1.121

SDQ peer relationship problems, post 15 .00 8.00 2.0667 2.46306 1.103 .580 .618 1.121

231

SDQ internalising difficulties, post 15 .00 13.00 4.1667 3.79693 1.037 .580 .504 1.121

SDQ externalising difficulties, post 15 3.00 13.00 7.8333 3.11486 .139 .580 -1.013 1.121

SDQ total difficulties, post 15 3.00 24.50 12.0000 6.00298 .436 .580 -.015 1.121

SDQ prosocial behaviour, post 15 2.00 9.00 5.9333 1.94447 -.498 .580 -.235 1.121

Mean MAAS-A score, post 15 2.64 5.38 4.1018 .74164 .043 .580 .075 1.121

AARS instrumental anger, follow up 14 20 31 24.50 3.937 .631 .597 -.948 1.154

AARS reactive anger, follow up 14 8 25 17.43 5.095 -.116 .597 -.727 1.154

AARS anger control, follow up 14 20 34 29.43 4.146 -1.043 .597 .691 1.154

AARS total anger, follow up 14 59 101 77.50 11.360 .404 .597 .040 1.154

SDQ emotional symptoms, follow up 13 .00 5.00 1.9038 1.57962 .725 .616 -.520 1.191

SDQ conduct problems, follow up 13 .00 8.00 2.9231 2.28989 .997 .616 .537 1.191

SDQ hyperactivity/inattention, follow up 13 1.00 9.00 4.6923 2.39390 .257 .616 -.590 1.191

SDQ peer relationship problems, follow up 13 .00 5.00 2.2692 1.64083 .419 .616 -.528 1.191

SDQ internalising difficulties, follow up 13 1.00 6.25 4.1731 1.97216 -.551 .616 -1.257 1.191

SDQ externalising difficulties, follow up 13 2.00 16.00 7.6154 4.25320 .492 .616 -.487 1.191

SDQ total difficulties, follow up 13 4.00 22.25 11.7885 5.09477 .506 .616 .338 1.191

SDQ prosocial behaviour, follow up 13 2.00 10.00 6.1538 1.90815 -.258 .616 1.824 1.191

Mean MAAS-A score, follow up 14 2.79 5.86 4.2957 .82621 -.025 .597 .100 1.154

Valid N (listwise) 13

232

Kolmogorov-Smirnova

Statistic df Sig.

AARS instrumental anger, pre .297 17 .000

AARS reactive anger, pre .081 17 .200*

AARS anger control, pre .248 17 .007

AARS total anger, pre .119 17 .200*

SDQ emotional symptoms, pre .194 17 .090

SDQ conduct problems, pre .227 17 .020

SDQ hyperactivity/inattention, pre .207 17 .052

SDQ peer relationship problems, pre .255 17 .004

SDQ internalising difficulties, pre .144 17 .200*

SDQ externalising difficulties, pre .156 17 .200*

SDQ total difficulties, pre .208 17 .049

SDQ prosocial behaviour, pre .192 17 .095

Mean MAAS-A score, pre .266 17 .002

AARS instrumental anger, post .381 15 .000

AARS reactive anger, post .188 15 .162

AARS anger control, post .215 15 .062

AARS total anger, post .191 15 .148

SDQ emotional symptoms, post .263 15 .006

SDQ conduct problems, post .207 15 .085

SDQ hyperactivity/inattention, post .113 15 .200*

SDQ peer relationship problems, post .268 15 .005

SDQ internalising difficulties, post .183 15 .191

SDQ externalising difficulties, post .145 15 .200*

SDQ total difficulties, post .170 15 .200*

SDQ prosocial behaviour, post .175 15 .200*

Mean MAAS-A score, post .173 15 .200*

AARS instrumental anger, follow up .220 14 .065

AARS reactive anger, follow up .116 14 .200*

AARS anger control, follow up .148 14 .200*

AARS total anger, follow up .160 14 .200*

SDQ emotional symptoms, follow up .255 13 .021

SDQ conduct problems, follow up .195 13 .189

SDQ hyperactivity/inattention, follow up .141 13 .200*

SDQ peer relationship problems, follow up .181 13 .200*

SDQ internalising difficulties, follow up .207 13 .130

SDQ externalising difficulties, follow up .156 13 .200*

SDQ total difficulties, follow up .178 13 .200*

SDQ prosocial behaviour, follow up .237 13 .044

Mean MAAS-A score, follow up .126 14 .200*

233

Example of normality graphs reviewed: SDQ total difficulties, post

234

235

Summary of normality analysesName of variable

Kolmogorov - Smirnov normal?

Histogram visual inspection normal?

Normal Q-Q plots, visual inspection normal?

Skewness Z score normal?

Kurtosis Z score normal?

Overall summary normal?

Outlier (as identified via box plot)?

AARS ins pre No No – positive skew

No 2.30 - no 0.05 - yes No Present

AARS reac pre Yes Yes Yes 0.65 - yes -0.23 – yes YesAARS control pre

No No – positive skew

Yes/No 1.89 - yes -0.04 - yes Yes/No Present

AARS total pre Yes Yes Yes 0.67 - yes -0.66 – yes YesSDQ Emo pre Yes Yes/No - slight

positive skewYes 1.23 – yes -0.19 - yes Yes

SDQ con pre No No – positive skew

Yes 1.44 – yes -0.54 – yes Yes

SDQ hyp pre Yes (marginal)

Yes Yes 0.52 - yes -1.00 – yes Yes

SDQ peer pre No Yes/No – slight positive skew

Yes 1.05 - yes -0.31 – yes Yes

SDQ int pre Yes Yes Yes 0.49 – yes -0.09 - yes YesSDQ ext pre Yes Yes Yes 0.49 - yes -0.84 - yes YesSDQ total diff pre

No (marginal)

Yes Yes -1.01 - yes -0.76 – yes Yes

SDQ prosocial pre

Yes Yes Yes 0.31 - yes -1.09 – yes Yes

Mean MAAS- No No – positive Yes/No 2.98 - no 2.17 – no No Present

236

A pre skewAARS ins post No Yes Yes/No 1.92 - yes -0.39 - yes Yes PresentAARS reac post

Yes Yes Yes 0.32 - yes -0.85 - yes Yes

AARS control post

Yes No – negative skew

Yes -1.38 – yes -0.36 – yes Yes

AARS total post

Yes No – positive skew

Yes 1.73 - yes 0.22 – yes Yes Present

SDQ Emo post No No – positive skew

Yes 1.32 - yes -0.78 – yes Yes

SDQ con post Yes Yes Yes 0.19 - yes 0.35 – yes YesSDQ hyp post Yes Yes Yes -0.02 - yes -0.40 – yes YesSDQ peer post No No – positive

skewYes/No 1.90 - yes 0.55 – yes Yes/No

SDQ int post Yes No – positive skew

Yes/No 1.79 - yes 0.45 – yes Yes Present

SDQ ext post Yes Yes Yes 0.24 - yes -0.90 – yes YesSDQ total diff post

Yes Yes Yes 0.75 - yes -0.01 – yes Yes Present

SDQ prosocial post

Yes Yes – slight negative skew

Yes -0.86 - yes -0.21 - yes Yes

Mean MAAS-A post

Yes Yes – slight negative skew?

Yes 0.07 - yes 0.07 – yes Yes Present

AARS ins follow up

Yes Yes Yes 1.06 - yes -0.82 – yes Yes

AARS reac Yes Yes Yes -0.19 - yes -0.63 – yes Yes

237

follow upAARS control follow up

Yes No - negative skew

Yes -1.75 - yes 0.60 – yes Yes

AARS total follow up

No Yes Yes 0.68 - yes 0.03 - yes Yes

SDQ Emo follow up

Yes Yes – slight positive skew

Yes 1.18 - yes -0.44 - yes Yes

SDQ con follow up

Yes No – positive skew

Yes 1.62 - yes 0.45 – yes Yes

SDQ hyp follow up

Yes Yes Yes 0.41 – yes -0.50 - yes Yes

SDQ peer follow up

Yes Yes Yes 0.68 - yes -0.44 - yes Yes

SDQ int follow up

Yes Yes – slight negative skew

Yes -0.89 - yes -1.06 - yes Yes

SDQ ext follow up

Yes Yes Yes 0.80 - yes -0.41 – yes Yes

SDQ total diff follow up

Yes Yes Yes 0.82 - yes 0.28 - yes Yes Present

SDQ prosocial follow up

No Yes Yes -0.42 - yes 1.53 – yes Yes Present

Mean MAAS-A follow up

Yes Yes Yes -0.04 - yes 0.09 - yes Yes

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Appendix 12 – Additional reliability analyses

Several of the questionnaires had a substantial proportion of negative inter-item correlations, casting doubt over the internal

consistency of the scale for this client group.

Scale Pre-group no. of -ve correlations

largest -ve corre-lation

% of total number of item correlations that are negative23

Post-group no. of -ve correlations

largest -ve corre-lation

% of total number of item correlations that are negative

Follow-up group no. of -ve correlations

largest -ve corre-lation

% of total number of item correlations that are negative

AARS control (13 qu’s)

7 -0.186 (7/78)*100 =8.97%

25 -0.357 (25/78)*10 0 =32.05%

28 -0.519 (28/78)*100 =35.9%

AARS instrumental (18 qu’s pre; 17 qu’s post; 15 qu’s follow-up)

22 (16 of which were qu22)

-0.24 (22/153)*100 =14.38%

42 -0.464 (42/136)*100 =30.88%

29 -0.284 (29/105)*100 =27.62%

AARS reactive (8 qu’s)

2 -0.091 (2/28)*100 =7.14%

4 -0.255 (4/28)*100 =14.28%

5 -0.315 (5/28)*100=17.86%

MAAS-A (14 qu’s)

31 (10 of which were

-0.448 (31/91)*100 =34.07%

27 -0.608 (27/91)*100 =29.67%

9 -0.334 (9/91)*100 =9.89%

23 Using AARS control as an example, “total number of item correlations” figure derived as follows. Total number of questions = 13. Therefore, total number of unique item correlations (excluding item-self perfect correlations) = ([13*13] – 13)/2 = 78.

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question 1)

SDQ prosocial (5 qu’s)

2 -0.205 (2/10)*100 =20%

2 -0.208 (2/10)*100 =20%

0 - -

SDQ hyper-activity (5 qu’s)

8 -0.203 (8/10)*100 =80%

1 -0.228 (1/10)*100 =10%

0 - -

SDQ emotional (5 qu’s)

2 -0.224 (2/10)*100 =20%

0 - - 5 -0.368 (5/10)*100 =50%

SDQ conduct (5 qu’s)

2 -0.163 (2/10)*100 =20%

2 -0.206 (2/10)*100 =20%

1 -0.022 (1/10)*100 =10%

SDQ peer (5 qu’s)

6 -0.291 (6/10)*100 =60%

0 - - 6 -0.463 (6/10)*100 =60%

SDQ total difficulties (5 qu’s)

82 ? (82/190)*100 =43.16%

55 -0.507 (55/190)*100 =28.95%

72 ? (72/190)*100 =37.89%

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Given the small number of items that make up the SDQ subscales (n=5) and

the reactive anger scale of the AARS (n=8), mean inter-item correlations were also

considered for these subscales as advised by Pallant (2010). Briggs and Cheek (1986)

suggest an optimal inter-item correlation range of 0.2-0.4. As can be seen below, the

SDQ scales regularly fall outside of this range, casting doubt over the internal

consistency of this scale for this client group, whilst the AARS reactive scale falls

within this range.

Scale Pre-group mean inter-item correlation

Post-group mean inter-item correlation

Follow-up mean inter-item correlation

AARS reactive 0.390 0.267 0.285SDQ prosocial 0.238 0.190 0.261SDQ hyperactivity -0.044 0.086 0.425SDQ emotional 0.115 0.273 0.059SDQ conduct 0.151 0.110 0.389SDQ peer -0.035 0.480 0.044

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Appendix 13 – Informal Process Notes Discussion

Interviews and journal notes were reviewed. Reading and reviewing this informal data

revealed that the facilitators observed several positive aspects of holding the groups in the

school, including the boys all being in the same building which facilitated attendance, and the

school being familiar with running additional groups. The facilitators also commented on

aspects of the group they would change in the future. This included having a greater number

of sessions to allow a slower pace, and having group sizes of less than seven as group one

was experienced as too large.

The facilitators reported several logistical challenges of running the group in the

school. They found it difficult to balance the dual role of group facilitator and assisting the

school-based co-facilitator with ensuring the boys adhered to school behaviour policies,

noting that they lacked authority due to unfamiliarity with school processes. The need for a

firm school facilitator was commented on. In addition, the participants did not always arrive

on time for groups and/or facilitators had to collect them from lessons, resulting in lost

session time. Last minute room changes and timetable clashes occurred on several occasions,

resulting in disorganised starts to some sessions. The facilitators suggested that embedding

future groups into the school timetable may overcome these issues, as well as the facilitators

raising the profile of the group with all school staff. The facilitators also experienced some

difficulty getting hold of parents at the start of each group to gain consent to participate,

requiring multiple attempts to contact them.

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Appendix 14 – Reflexive Account of Qualitative Analysis Process

This account summarises the processes through which I engaged with the qualitative

data throughout all stages of the research. It aims to highlight the obstacles and challenges I

faced to maintain an objective, honest and credible account of the data, and how I attempted

to overcome these.

I approached the qualitative aspect of my project from a position of “critical-realism”.

Given the mixed-methods nature of the project, a critical-realist epistemological position

provided a coherent framework for the project. Adopting a more social-constructionist

interpretation of the data (for example) would not have allowed coherent integration with the

quantitative data, whilst adopting a purely realist approach would have lost some of the

subtleties of the focus group. The critical-realist position enabled integration of the two types

of data, whilst still allowing some interpretation of the nuances within the qualitative data.

I was very aware of the multitude of roles I was managing through the qualitative

data collection and analysis processes. On the one hand, I was a “scientist-practitioner” and

“researcher”, keen to establish the “facts” of the data, and aiming to minimise bias in

interpretation. However, I was simultaneously acknowledging my role as the developer and

facilitator of the group, and the inherent bias that this could introduce. The group was, after

all, an innovative and creative product which engaged intellectual effort and many hours of

work. Furthermore, I also held the role of trainee clinical psychologist, with the natural

curiosity of “reading between the lines” that this role can bring. Finally, I brought my own

humanness, including my own values, biases and history. I was conscious that the “hat” I

needed to be wearing for this task was that of “researcher”, but acknowledged that my other

roles would carry some influence.

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Elliott, Fischer and Rennie (1999) suggest guidelines against which qualitative

research should be evaluated. These include 1) Owning one’s perspective; 2) Situating the

sample; 3) Grounding in examples; 4) Providing credibility checks; 5) Coherence (of

analyses); 6) Accomplishing general versus specific research tasks; and 7) Resonating with

readers. Whilst my approach to analysis falls in line with each of the criteria, Elliott et al.

(1999) observe that these are only suggested to be guidelines, as opposed to a rigid checklist

to adhere to. In addition, Willig (2008) emphasises the relevance of the epistemological

position and associated evaluation; i.e. it would not make sense to adopt evaluation centred

on “objectivity” and “reliability” for a social constructionist informed analysis, however this

does fit better with a critical-realist analysis. Given this, the analysis process and audit trail

evidences my attempt to retain objectivity and reliability. A detailed breakdown of the audit

process is available in appendix 8 and is described in brief below.

In an attempt to allow the “researcher” position to take a dominant role, during the

focus groups themselves I was aware that there would be a temptation to explore things that I

personally thought were interesting and/or helpful, and that I had hoped the boys would have

found interesting and/or helpful too (e.g. specific ACT-related exercises). I attempted to

guard against this by devising a relatively structured interview format with the assistance of a

colleague and supervisor, to broaden my perspective on what would be helpful to ask the

boys. The relatively structured format of the focus group also allowed me to summarise and

reflect back to the boys to seek clarification, in reference to the questions posed rather than

avenues I wished to explore, and curtailed my curiosity. However this clarification and

reflection process brought my language to the transcripts, not just the boys, potentially

introducing a different perspective, given our obvious diverse differences of age / ethnicity /

gender / culture.

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During the transcription and analysis phases, I paid meticulous attention to detail,

transcribing all the utterances and nuances of the boys’ discussions, with the only exception

being when we were completely off-topic because a behavioural incident occurred that

required managing. However, there were certain occasions when I actively permitted my lens

as a trainee clinical psychologist to influence the interpretation process. The boys were

discussing when to schedule the groups, and it became apparent through some of their

language, as well as my knowledge of the school, and the boys themselves, that what they

explicitly said was different to what they meant. They gave “reasons” why it was helpful to

have the intervention on specific days, but their side conversations, comments from other

boys, and some individuals’ direct admissions, clearly inferred that it was to avoid

traditionally disliked subjects (maths, humanities). To ignore this “other” information would

have portrayed the data in a misrepresentative way, hence why I considered this added layer

of interpretation was relevant. This was checked with my colleague and co-facilitator who

agreed with this interpretation. In addition, the boys discussed wanting more games and food

as something they would change about the group; my interpretation of this was that they

viewed the group as potentially an “easy option”, and coded this as such, in addition to

coding the explicit content where appropriate.

Throughout all stages of interacting with the qualitative data, I was acutely aware of

my lens as the “facilitator” and “co-creator” of the group, as this had potential to introduce

the bias of wanting to find a “good” result. To guard against this, I followed a systematic

process of interacting with the data, detailed in appendix 8. I coded the data thoroughly and

repeatedly line-by-line, to ensure all data was coded as opposed to just the sections that were

important to me as the “facilitator” and “co-creator”. I then re-read transcripts and re-

generated ideas for codes without having the initial codes present, in an attempt to promote

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“fresh” readings of the transcripts, and to promote reliability of the codes. Codes were then

organised and re-organised into themes several times, and included consultation from the

research supervisor on initial theme generation. Transcripts were re-read two months after

tentative final themes were generated, and minor further tweaks to codes and themes were

made. The research supervisor also reviewed samples of the transcripts, and all audit

documents to add an additional reliability check on the process. Willig (2008) suggests

“triangulation” may be helpful for more positivist results, including the use of second coders.

This was attempted via the research supervisor’s aforementioned involvement, as well as my

repeated readings of the transcripts and codes, particularly the “blind” second stage coding.

Salience of themes was decided upon in reference to those that enabled the greatest

understanding of the research questions posed. This reduced the opportunity for my personal

biases to influence the decisions over what were the most important themes. Whilst certain

codes and associated themes occurred more frequently in transcripts (e.g. “pacing of group”),

they did not significantly assist in the understanding of the research questions, and therefore

were not provided the same status as other themes. For example, the “Changes” theme was

particularly useful for research question 1, and the “Content” theme for questions 1 and 3.

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Appendix 15 – Anger Control Subscale Questions – Removed for E-thesis

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Part 3 – Summary of Clinical Experience

1st year – Secondary Care Adult Mental Health (CMHRS) – 1 year.

My first-year clinical placement took place in a mental health team for adults with

severe and enduring mental health difficulties. The clients had received a range of diagnoses

such as bipolar disorder, borderline personality disorder, schizophrenia, depression, and a

variety of anxiety disorders. I worked with adults in acute distress, particularly for those

individuals where there was a history of trauma. My role entailed delivering individual and

group therapy, completing cognitive assessments (including using the WAIS-IV and WMS-

IV), and completing a service evaluation. My primary theoretical models were CBT and

ACT. My service evaluation looked at a new referral pathway that had been implemented and

provided the team with useful data and recommendations with regard to waiting lists.

2nd year – Community Adult Learning Disability – 6 months.

I completed six months in a multi-disciplinary community team for adults with

learning disability. This required both independent and joint work / liaison with other

professionals in the team. Responsibilities included individual therapy and family-based

intervention (CBT, narrative, systemic), indirect work with family and staff, dementia

assessments, assessment for learning disability diagnosis, sexual knowledge assessments, and

providing consultation to day centres. I also completed a piece of service development work,

by designing and delivering "ACT for staff"; a series of lunchtime workshops aimed at

promoting staff wellbeing.

2nd year – Tier 3 CAMHS / CAMHS learning disability – 6 months.

My core six-month child placement was split between a tier 3 child and adolescent

(CAMHS) mental health service, and a specialist CAMHS learning disability team. I was

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thus able to work with children and young people who were experiencing mental health

difficulties across a spectrum of developmental pathways, including those with a diagnosis of

learning disability, autism, and indeed those children who were “typically” developing.

My responsibilities included individual therapy (informed by CBT, narrative, and systemic

theories), indirect interventions (informed by attachment, neurodevelopment, and positive

behaviour support theories), and half a day per week in a family therapy team in both

reflecting team and lead therapist roles. In addition, I undertook cognitive assessments using

the WISC-IV and BADS-C and completed a stage 1 ASC assessment. The placement

involved joint work with other professionals (e.g. occupational therapist), as well as

providing consultation to other professionals (e.g. to schools). In addition, I took a lead role

in designing and co-facilitating an emotion regulation group for children with anxiety and

learning disabilities. 

3rd year – Older Adults Community Mental Health Team and Memory

Assessment Service - 6 months.

I completed a six-month placement working with older adults (aged 65 +) with mental

health needs and / or cognitive difficulties. My role required individual therapy, facilitation of

a cognitive stimulation therapy group, providing consultation to other staff members, and

completing memory assessments for the purposes of diagnosing dementia and other

neurodegenerative conditions. The therapeutic work adopted an integrative framework,

incorporating elements of CBT, narrative therapy, and compassion-focused therapy.

3rd year – Specialist Placement in Paediatrics – 6 months.

My specialist placement involved working with children and adolescents who were

experiencing a range of physical health problems and had associated psychological needs.

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Physical health problems included diabetes, cancer, procedural anxiety, brain injury,

medically unexplained symptoms, and pain. I also completed a formal developmental

assessment with a pre-school child with suspected developmental delay. I worked with both

the individual and their families. In addition, I provided consultation to medical teams when

psychological issues were identified in clinic appointments. The majority of children were

seen as outpatients, although some inpatient consultation also occurred. I also completed

service development work, including developing resources, and designing a new workshop

for helping parents to communicate with their teenagers.

Additional general experiences over the course of all placements

All placements required me to complete some form of formal psychometric

assessment. Tests completed over the course of placements include the following: WAIS-IV,

WMS, ToPF, CAMDEX-DS, RBANS, ToMM, WISC-IV, BADS-C, NAID, Hayling and

Brixton, Boston Naming Test, and subtests of several other tests. I have also completed

functional skills assessments (e.g. HALO, ABAS, etc), and a developmental assessment

(Bayley’s).

I have typically evaluated my therapeutic work using a range of formal and informal

outcomes measures, including questionnaires (e.g. SDQ, RCADS, PHQ-9, GAD-7, etc),

qualitative feedback (e.g. experience of service questionnaire), and person-specific goal-

based measures.

I have delivered presentations and teaching workshops to a variety of audiences

including staff teams, parents and carers of clients, and assistant psychologists. These have

been on a variety of topics including ACT, executive functioning, emotion regulation,

communication, and boundaries.

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Part 4 – Table of Assessments Completed During Training

Year I AssessmentsASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity

Summary of assessment and formulation with a male in his early 20s presenting with anxiety difficulties

Audio Recording of Clinical Activity with Critical Appraisal

Cognitive behavioural therapy for anxiety: Exposure therapy session with “Kate”

Report of Clinical Activity N=1

Cognitive behavioural therapy with “Kate”: A female in her early 20s presenting with a range of anxiety difficulties

Major Research Project Literature Survey

Anger and aggression in adolescent males

Major Research Project Proposal

A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males.

Service-Related Project Evaluation of the efficiency of the newly implemented referral pathway for clients with borderline personality disorder

Year II AssessmentsASSESSMENT TITLE

Report of Clinical Activity – Formal Assessment

Does “John” have an intellectual disability and/or autism? What are “John’s” strengths and weaknesses in relation to his cognitive skills and his functional, adaptive skills? A report of the assessment process carried out with “John”, a White-British male in his early 60s, to establish diagnosis, ascertain strengths and weaknesses, and to recommend appropriate ongoing support.

PPLD Process Account

Team PPD: A reflective account of individual and group development through participation in PPD groups

Presentation of Clinical Activity

Extended assessment, formulation, and indirect intervention with “Georgie”

Year III Assessments ASSESSMENT TITLE

Major Research Project Literature Review

Psychological interventions for anger and aggression in adolescent males: A systematic review of 21st Century interventions

Major Research Project Empirical Paper

Taking ACTion on Anger: A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males in a school-context.

Final Reflective Account

From “thinking”, to “feeling”, to reflecting, to formulating: My ongoing journey towards becoming a bio-psycho-socially-informed, reflective-scientist-practitioner

Report of An integrative assessment, formulation and intervention with “Ruby”: A

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Clinical Activity female in her late 70s presenting with low mood and adjustment difficulties.

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