Acceptance and Commitment Therapy for children: A systematic review of intervention studies
Introduction
Acceptance and Commitment Therapy (ACT) is a contemporary behavioural and cognitive therapy that works to foster increasing flexibility in response to thoughts, feelings and sensations through processes of mindfulness, acceptance, and behaviour change (Hayes et al., 2013, Wilson et al., 2011). In ACT the focus of change interventions is the context in which psychological phenomena occur, rather than the direct change attempts of their content/validity or frequency, as typified by traditional cognitive behaviour therapy (CBT; Blackledge et al., 2009, Hayes, 2004, Hayes et al., 2011).
ACT is underpinned by a theoretical framework, termed relational frame theory (RFT; S.C. Hayes et al., 2011). RFT focuses on human language and cognitive processes and suggests that with language development we learn to continually derive relations between events. From childhood we learn to relate events to each other on the basis of social convention and to derive meaning from events on the basis of this relating, termed in ACT “learned derivation” (Luoma, Hayes, & Walser, 2007). For example, during early language training interactions, children are often shown objects and asked to repeat their names. A mother may then clap her hands, or say, “That’s right, a car!”, reinforcing the spoken word “car” with the object, car. The child may also be taught the name of the car, so object-word and word-object relation is explicitly trained. With sufficient repetitions learned derivation occurs. The child is then able to generalise the spoken word car to a toy car, and to the printed words “toy car”, and vice-versa.
Whilst learned derivation offers evolutionary advantages, it can also act as a hindrance. When language is taken literally this can result in a “fusion” with thinking (i.e. experience one׳s own thoughts and beliefs as literally true), and can lead to pain (Harris, 2009). In ACT this is termed cognitive fusion. To illustrate, fusing with the thought that “life is unbearable” might produce depressive symptoms despite the existence of various things required to live a full life, such as meaningful employment and supportive relationships (Hayes, Pistorello, & Levin, 2012). Cognitive fusion in turn leads to a whole host of reactions, known as “experiential avoidance”, such as excessive use of problem solving, active efforts to escape or avoid feelings, and entanglement in thinking; methods employed as a way to solve our pain (Luoma et al., 2007). These methods result in a loss of contact with the present, belief in negative stories about ourselves, and rigidity in our way of living. Life becomes less about opening up in the pursuit of things that are important, but tends to result in an overall narrowing of living to support freedom from distress (Harris, 2009). In ACT this is termed psychological inflexibility.
ACT employs six interrelational core therapeutic processes that form a “hexaflex” model of psychological flexibility; acceptance, cognitive defusion, mindfulness, self-as-context, committed action, and valued living (Luoma et al., 2007). Acceptance is employed as the antithesis to experiential avoidance. The focus is on opening up to thoughts, feelings and sensations in order to increase the behaviour repertoire and allow for action that is in line with what is important (Hayes et al., 2012). To counteract cognitive fusion, clients learn to change the way they relate to their thoughts, and thereby decrease their attachment to these. For children, metaphors and experiential exercises help the child recognise a thought for what it is, just a bunch of words, and not what it says it is. Mindfulness is utilised to reduce problematic attentional patterns, that are past focused or future orientated (Hayes et al., 2012), in order to reduce cognitive errors such as rumination (past) or catastrophising (future). Clients are taught mindfulness approaches to increase their skills in staying present focused. Approaches may range from formal meditation exercises to deliberately averting “auto-pilot” by deliberately focusing on the here-and-now experience of activities of daily living such as breathing, walking or riding a bike (Harris, 2009). Self-as-context is best conceptualised as a perspective taken from the sense of self, or the ability of humans to consciously notice themselves doing, thinking or experiencing things whilst they are occurring. Therapeutically, contact with the self-as-context is achieved via mindfulness and perspective-taking (Hayes et al., 2012). Values identification is employed to assist in living life the way that is meaningful to each individual, supporting the identification of those tenets that may act as a compass to future action and as intrinsic reinforcers to the continuation of this behaviour (Hayes et al., 2012). For children this is working through what really matters to them at school, home and/or in their friendships for example. Committed action advocates engaging in behaviour that is in line with personal values for living, moment-by-moment, this often takes the appearance of behaviour change goals such as behavioural activation or exposure (Hayes et al., 2012). These approaches from the hexaflex are deployed to foster the attainment of increasingly flexible methods of managing challenging cognitions, emotions or sensations, thereby diminishing their deleterious behavioural consequences (Arch & Craske, 2008).
ACT has a growing evidence base in the treatment of adult psychopathology, with numerous reviews and meta-analyses demonstrating its efficacy (e.g., Hayes et al., 2006, Levin and Hayes, 2009, Ruiz, 2012). There has also been considerable interest in the adaptation and assessment of the suitability of ACT approaches among child and adolescent populations (e.g., Coyne et al., 2011, Greco et al., 2005, Murrell and Scherbarth, 2006). Reviews have found other psychotherapeutic approaches, such as traditional CBT, to be effective in the treatment of children with various presenting problems (AACAP, 2007, AACAP, 2012, James et al., 2013, Weisz et al., 2006). However, their effectiveness has been found to be modest (Weisz et al., 2006) and/or superior to no treatment, but not active control conditions (James et al., 2013). Finally, a recent review concluded that CBT is not necessarily the most effective form of treatment for young people, but the only one that has been researched enough to provide evidence to support its use (Creswell, Waite, & Cooper, 2014). Thus there is room for improvement and there is a need for more rigorous research into alternative treatments to support evidence based clinical practice.
Stemming from the cognitive behavioural tradition and with a strong theoretical basis, ACT has been proposed as a transdiagnostic therapy, a unified treatment applicable to a range of presenting problems and clinical diagnoses (Hayes et al., 2012, Livheim et al., 2014). One possible mechanism through which this may occur is via ACT׳s focus on experiential avoidance. A recent review linked experiential avoidance to an array of psychopathology, finding experiential avoidance predicts symptom severity in specific disorders, affects relapse and can act as a mediator for psychological distress and coping (Chawla & Ostafin, 2007). If ACT were found to work effectively as a transdiagnostic approach this would reduce the load on clinicians to gain familiarity and competence with a whole host of diagnosis-specific evidence-based intervention (Farchione et al., 2012). This lends itself to the potential to work across contexts, with diverse child and adolescent populations and for clinicians to readily increase their expertise in intervention delivery.
More research incorporating ACT processes of change is required, including into experiential avoidance, to better elucidate this, particularly among children. Research on the ACT core processes and their relation to QOL, or psychosocial and well-being outcomes, among children demonstrates that these processes operate in a similar way to that of adults (for a review see Coyne et al., 2011). Feasibility studies also offer support for the utility of mindfulness-based approaches, such as ACT, with children (Burke, 2010). It has been argued that as children think less literally than adults, the employment of metaphors and experiential approaches may allow children to grasp abstract concepts through experience (O׳Brien, Larson, & Murrell, 2008). Preliminary research with children as young as four suggests provides some evidence for this assertion (Heffner, Greco, & Eifert, 2003). Furthermore, it has been purported that children have had less time to adopt more entrenched patterns of experiential avoidance and as such, ACT may operate to achieve both the remediation, and prevention, of the onset of inflexible patterns of psychological responding (Greco et al., 2005). ACT approaches may also be well-suited to adolescents as they assist in rapport building and are less instructive (Greco et al., 2005). ACT׳s focus on experiential, or personal learning, approaches support autonomously-driven behaviour that may be particularly appropriate for adolescents desiring increased independence who may be non-responsive to adult direction (Hadlandsmyth, White, Nesin, & Greco, 2013). The emphasis on values may also be pertinent for adolescents due to the exploratory nature of, and increasing capacity for abstract thinking during, this developmental period (Greco et al., 2005).
There are two existing reviews of the ACT literature among children, however, neither have been conducted systematically. Systematic reviews of psychotherapeutic research aim to synthesise the academic literature, using a predefined scientific method to answer a specific clinical question, whilst minimising bias, and support the delivery of evidence-based treatment (Mulrow, 1994). Systematic reviews also identify and analyse the methodological rigour of included studies to support clinician׳s to comprehend the validity of the findings to their clients as well as support the conduct of future research endeavours (Mulrow, 1994). Both existing reviews of the ACT literature for children Murrell and Scherbarth (2006) and Coyne et al. (2011) examined 15 studies, which incorporated unpublished data from conference presentations not subjected to peer-review, parenting interventions, theoretical studies, and a study with an absence of psychometric measures. Neither examined unpublished university theses or dissertations. Whilst exclusive reliance on published literature in reviews may produce publication bias (McLeod & Weisz, 2004), potentially overstating the positive nature of treatment results, it has been argued that unpublished studies are unsuitable for systematic reviews due to their inferior methodological rigour. However, studies that have examined the rigour of grey literature, academic unpublished literature that has not been subjected to widespread peer review by the scientific community, have found that theses and dissertations may contain more, or equivalently, stringent methodology than that found within published studies (Hopewell et al., 2007, McLeod and Weisz, 2004). Whilst any form of unpublished academic literature might be considered to be grey literature, theses and dissertations have the advantage of undergoing peer review from a (albeit, small) number of reviewers. Therefore, it would seem that unpublished theses and dissertations have the capacity to reduce publication bias, whilst maintaining methodological quality, and strengthen the empirical base into populations for which there is a paucity of research. In this way, a systematic review supports clinicians and researchers to benefit from the synthesis of a greater wealth of research where bias is minimised to support translation into clinical and academic practice.
Evaluation of the methodological stringency of ACT research may be particularly salient, as a previous systematic review and meta-analysis of the adult literature, concluded methodological concerns are more typical in ACT research than in traditional CBT and that ACT did not met the requirements to be an “empirically supported treatment” (Ost, 2008). However, the conclusions of this review are not without contention. Gaudiano (2009) argued that the strategy utilised by Ost to compare methodological quality of ACT and CBT was mismatched, with the majority of ACT studies conducted among populations widely acknowledged to be treatment-resistant. ACT and CBT were also noted to be at markedly different stages of clinical trial research and associated grant support, favouring CBT, which was moderately correlated with methodological rigour (Gaudiano, 2009). Whilst this review was not without criticism, Ost was commended for attempting to evaluate the methodological stringency of the literature when making conclusions on its applicability for clinical practice (Gaudiano, 2009).
In summary, whilst two previous reviews of ACT for children have been conducted, these are subject to several limitations including non-scientific approaches and the inclusion of studies that are purely theoretical or not subjected to peer-review. At the time of the publication of the most recent review, few empirical studies had been conducted and those that were available were predominantly case studies or uncontrolled pilots (Coyne et al., 2011). In the past few years the ACT literature has seen a proliferation of studies involving child and adolescent populations. As an increasing number of studies are now available there is a growing need for a systematic review of the utility of ACT for children. The current investigation aims to address this gap in the literature by providing an integrated synthesis of both the published and unpublished literature for ACT in the treatment of children that incorporates both an exploration of findings and an evaluation of the methodological rigour of included studies. The diverse literature will be synthesised to elucidate generalisations, consistencies and inconsistencies in research findings to enable evidence-based clinical decision-making in this area and minimise bias (Higgins and Green, 2011, Mulrow, 1994). The analysis of the methodological rigour of included studies will also offer ecological validity information to assist clinicians in translating research into practice. To the authors׳ knowledge, this is the first systematic review to specifically focus upon children.
Section snippets
Search and screening procedures
Electronic searches of the PsycInfo and PsycArticles and PsycExtra databases were undertaken to obtain the published literature. Whilst no date restrictions were employed, the search was conducted in December 2014 and therefore included literature available up to this time. Considered to be an international online learning and research community for researchers and clinicians with an interest in ACT, the Association for Contextual Behavioral Science webpage (http://contextualscience.org/) was
Overview of included studies
Table 1 provides an overview of included studies. Studies included a total of 707 participants and incorporated treatment for children with anorexia nervosa, depression, pain, trichotillomania, sickle cell disease, tic disorders, obsessive-compulsive disorder, anxiety symptoms, posttraumatic stress disorder (PTSD)/posttraumatic stress symptoms (PTS), impulsivity/problem/sexualised behaviour, self-harm, stress symptoms, emotional dysregulation, Aspergers Syndrome, and attention deficit
Discussion
The past few years has seen a proliferation of ACT research in the treatment of conditions among children. While there are two existing reviews of the literature, the present investigation is the first to be conducted systematically. It involved both the published literature as well as unpublished theses/doctoral dissertations and specifically targeted studies involving treatment for children, rather than parent-based interventions. It also expands upon the findings of earlier reviews through
Conclusion
Emerging research of ACT in the treatment of children is encouraging for the utility of this therapeutic approach for clinicians working with young people. To consolidate and build upon this preliminary evidence, larger methodologically rigorous trials are required across a broader spectrum of presenting problems and particularly among younger children. As difficulties in childhood can result in substantial impairment across various life domains, it is important that appropriate,
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