Journal of Child and Family Studies

, Volume 24, Issue 4, pp 1016–1030 | Cite as

The Effectiveness of Acceptance and Commitment Therapy for Adolescent Mental Health: Swedish and Australian Pilot Outcomes

  • Fredrik LivheimEmail author
  • Louise Hayes
  • Ata Ghaderi
  • Thora Magnusdottir
  • Anna Högfeldt
  • Julie Rowse
  • Simone Turner
  • Steven C. Hayes
  • Anders Tengström
Original Paper


Depression, anxiety and stress are common problems among adolescents. Teaching young people coping strategies in school-based intervention programs is one promising approach hoped to remedy the negative consequences of distress in adolescence. The aim of the two pilot studies was to examine the effect of a brief intervention based on the principles of Acceptance and Commitment Therapy (ACT) on depressive symptomatology (Australian study, N = 66) and stress (Swedish study, N = 32) among adolescents screened for psychosocial problems in school settings. In both studies, subjects were assigned to receive the ACT-group-intervention, or a control intervention featuring individual support from the school health care. The Australian study was a planned comparison, with random allocation for girls, plus one replication of a boys group. The Swedish study used a randomized controlled design. The ACT-intervention was an 8-session manualized group program. The Australian study showed significant reductions in depressive symptoms with a large effect, and significant reductions in psychological inflexibility with a medium effect when compared to the control group who received standard care. In the Swedish study, the ACT-intervention group, when compared to the control group, reported significantly lower levels of stress with a large effect size, and marginally significant decrease of anxiety, and marginally significant increased mindfulness skills. Taken together, the ACT-intervention seems to be a promising intervention for reducing stress and depressive symptoms among young adolescents in school and should be tested in full-sized studies. Limitations of these two pilots include small samples.


Adolescent depression Adolescent stress ACT (Acceptance and commitment therapy) School intervention 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. Bethay, J. S., Wilson, K. G., Schnetzer, L. W., Nassar, S. L., & Bordieri, M. J. (2013). A controlled pilot evaluation of acceptance and commitment training for intellectual disability staff. Mindfulness, 4(2), 113–121. doi: 10.1007/s12671-012-0103-8.CrossRefGoogle Scholar
  2. Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention Science, 9(3), 139–152. doi: 10.1007/s11121-008-0099-4.CrossRefPubMedCentralPubMedGoogle Scholar
  3. Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5(1), 156–163. doi: 10.1037//1076-8998.5.1.156.CrossRefPubMedGoogle Scholar
  4. Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour Research and Therapy, 49(6–7), 389–398. doi: 10.1016/j.brat.2011.03.009.CrossRefPubMedGoogle Scholar
  5. Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour Research and Therapy, 35(1), 79–89. doi: 10.1016/s0005-7967(96)00068-x.CrossRefPubMedGoogle Scholar
  6. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. doi: 10.1037/0022-3514.84.4.822.CrossRefPubMedGoogle Scholar
  7. Calear, A. L., & Christensen, H. (2010). Systematic review of school-based prevention and early intervention programs for depression. Journal of Adolescence, 33(3), 429–438. doi: 10.1016/j.adolescence.2009.07.004.CrossRefPubMedGoogle Scholar
  8. Campbell, A., Walker, J., & Farrell, G. (2003). Confirmatory factor analysis of the GHQ-12: Can I see that again? Australian and New Zealand Journal of Psychiatry, 37(4), 475–483. doi: 10.1046/j.1440-1614.2003.01208.x.CrossRefPubMedGoogle Scholar
  9. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.Google Scholar
  10. Cohen, S., & Janicki-Deverts, D. (2012). Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. Journal of Applied Social Psychology, 42(6), 1320–1334. doi: 10.1111/j.1559-1816.2012.00900.x.CrossRefGoogle Scholar
  11. Cohen, S., Kessler, R. C., & Underwood Gordon, L. (1995). Measuring stress: A guide for health and social scientists. New York, NY: Oxford University Press.Google Scholar
  12. Duckworth, A. L., Kim, B., & Tsukayama, E. (2013). Life stress impairs self-control in early adolescence. Frontiers in Psychology, 3, 608. doi: 10.3389/fpsyg.2012.00608.CrossRefPubMedCentralPubMedGoogle Scholar
  13. Eskin, M., & Parr, D. (1996). Introducing a Swedish version of an instrument measuring mental stress (Reports from the Department of Psychology, No. 813). Stockholm, Sweden: Stockholm University.Google Scholar
  14. Flaxman, P. E., & Bond, F. W. (2010a). A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training. Behaviour Research and Therapy, 48(8), 816–820. doi: 10.1016/j.brat.2010.05.004.CrossRefPubMedGoogle Scholar
  15. Flaxman, P. E., & Bond, F. W. (2010b). Worksite stress management training: Moderated effects and clinical significance. Journal of Occupational Health Psychology, 15(4), 347–358. doi: 10.1037/a0020522.CrossRefPubMedGoogle Scholar
  16. Flay, B. R., Biglan, A., Boruch, R. F., Castro, F. G., Gottfredson, D., Kellam, S., et al. (2005). Standards of evidence: Criteria for efficacy, effectiveness and dissemination. Prevention Science, 6(3), 151–175. doi: 10.1007/s11121-005-5553-y.CrossRefPubMedGoogle Scholar
  17. Gao, F., Luo, N., Thumboo, J., Fones, C., Li, S. C., & Cheung, Y. B. (2004). Does the 12-item General Health Questionnaire contain multiple factors and do we need them? Health and Quality of Life Outcomes, 2, 63. doi: 10.1186/1477-7525-2-63.CrossRefPubMedCentralPubMedGoogle Scholar
  18. Goodman, R. (2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1337–1345. doi: 10.1097/00004583-200111000-00015.CrossRefPubMedGoogle Scholar
  19. Goodman, R., Meltzer, H., & Bailey, V. (2003). The strengths and difficulties questionnaire: A pilot study on the validity of the self-report version. International Review of Psychiatry, 15(1–2), 173–177. doi: 10.1080/0954026021000046137.CrossRefPubMedGoogle Scholar
  20. Grant, K. E., Compas, B. E., Thurm, A. E., McMahon, S. D., & Gipson, P. Y. (2004). Stressors and child and adolescent psychopathology: Measurement issues and prospective effects. Journal of Clinical Child & Adolescent Psychology, 33(2), 412–425. doi: 10.1207/s15374424jccp3302_23.CrossRefGoogle Scholar
  21. Greco, L. A., Baer, R. A., & Lambert, W. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. doi: 10.1037/1040-3590.20.2.93.CrossRefPubMedGoogle Scholar
  22. Hankin, B. L., Mermelstein, R., & Roesch, L. (2007). Sex differences in adolescent depression: Stress exposure and reactivity models. Child Development, 78(1), 279–295. doi: 10.1111/j.1467-8624.2007.00997.x.CrossRefPubMedGoogle Scholar
  23. Hayes, L. L., Boyd, C. P., & Sewell, J. (2011). Acceptance and commitment therapy for the treatment of adolescent depression: A pilot study in a psychiatric outpatient setting. Mindfulness, 2(2), 86–94. doi: 10.1007/s12671-011-0046-5.CrossRefGoogle Scholar
  24. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. doi: 10.1016/j.brat.2005.06.006.CrossRefPubMedGoogle Scholar
  25. Hayes, L. L., & Rowse, J. (2008). Acceptance and commitment therapy: Experiential adolescent group. Retrieved from Association for Contextual Behavioral Science website:
  26. Hayes, S. C., & Strosahl, K. D. (Eds.). (2004). A practical guide to acceptance and commitment therapy. New York, NY: Springer.Google Scholar
  27. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.Google Scholar
  28. Heffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002). Acceptance and commitment therapy in the treatment of an adolescent female with anorexia nervosa: A case example. Cognitive and Behavioral Practice, 9(3), 232–236. doi: 10.1016/s1077-7229(02)80053-0.CrossRefGoogle Scholar
  29. Hewitt, P. L., Flett, G. L., & Mosher, S. W. (1992). The perceived stress scale: Factor structure and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology and Behavioral Assessment, 14(3), 247–257. doi: 10.1007/BF00962631.CrossRefGoogle Scholar
  30. Horowitz, J. L., Garber, J., Ciesla, J. A., Young, J. F., & Mufson, L. (2007). Prevention of depressive symptoms in adolescents: A randomized trial of cognitive-behavioral and interpersonal prevention programs. Journal of Consulting and Clinical Psychology, 75(5), 693–706. doi: 10.1037/0022-006x.75.5.693.CrossRefPubMedGoogle Scholar
  31. Jakobsson, C., & Wellin, J. (2006). Acceptance and commitment therapy and stress in school: A two year follow up of a randomized controlled trial (Master′s thesis, Uppsala University, Sweden). Retrieved from
  32. Keenan-Miller, D., Hammen, C. L., & Brennan, P. A. (2007). Health outcomes related to early adolescent depression. Journal of Adolescent Health, 41(3), 256–262. doi: 10.1016/j.jadohealth.2007.03.015.CrossRefPubMedGoogle Scholar
  33. Livheim, F. (2004). Acceptance and commitment therapy in school setting: To cope with stress, a randomized controlled trial (Master′s thesis, Uppsala University, Sweden). Retrieved from
  34. Merry, S. N., Hetrick, S. E., Cox, G. R., Brudevold-Iversen, T., Bir, J. J., & McDowell, H. (2011). Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews, 2011(12), Art. No.: CD003380. doi: 10.1002/14651858.CD003380.pub3.
  35. Merry, S. N., McDowell, H., Hetrick, S., Bir, J., & Muller, N. (2004). Psychological and/or educational interventions for the prevention of depression in children and adolescents. Cochrane Database of Systematic Reviews, Art. No.: CD003380. doi: 10.1002/14651858.CD003380.pub2.
  36. Merry, S. N., & Spence, S. H. (2007). Attempting to prevent depression in youth: A systematic review of the evidence. Early Intervention in Psychiatry, 1(2), 128–137. doi: 10.1111/j.1751-7893.2007.00030.x.CrossRefGoogle Scholar
  37. Metzler, C. W., Biglan, A., Noell, J., Ary, D. V., & Ochs, L. (2000). A randomized controlled trial of a behavioral intervention to reduce high-risk sexual behavior among adolescents in STD clinics. Behavior Therapy, 31(1), 27–54. doi: 10.1016/s0005-7894(00)80003-9.CrossRefGoogle Scholar
  38. Montazeri, A., Hole, D. J., Milroy, R., McEwen, J., & Gillis, C. R. (2004). Does knowledge of cancer diagnosis affect quality of life? A methodological challenge. BMC Cancer, 4(21). doi: 10.1186/1471-2407-4-21.
  39. Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academies Press.Google Scholar
  40. Muris, P., Meesters, C., Eijkelenboom, A., & Vincken, M. (2004). The self-report version of the strengths and difficulties questionnaire: Its psychometric properties in 8- to 13-year-old non-clinical children. British Journal of Clinical Psychology, 43(4), 437–448. doi: 10.1348/0144665042388982.CrossRefPubMedGoogle Scholar
  41. Neto, F. (1993). The satisfaction with life scale: Psychometric properties in an adolescent sample. Journal of Youth and Adolescence, 22(2), 125–134. doi: 10.1007/BF01536648.CrossRefGoogle Scholar
  42. Ost, L.-G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296–321. doi: 10.1016/j.brat.2007.12.005.CrossRefPubMedGoogle Scholar
  43. Parker, G., & Roy, K. (2001). Adolescent depression: A review. Australian and New Zealand Journal of Psychiatry, 35(5), 572–580. doi: 10.1046/j.1440-1614.2001.00934.x.CrossRefPubMedGoogle Scholar
  44. Pavot, W., & Diener, E. (1993). Review of the satisfaction with life scale. Psychological Assessment, 5(2), 164–172. doi: 10.1037/1040-3590.5.2.164.CrossRefGoogle Scholar
  45. Politi, P. L., Piccinelli, M., & Wilkinson, G. (1994). Reliability, validity and factor structure of the 12-item General Health Questionnaire among young males in Italy. Acta Psychiatrica Scandinavica, 90(6), 432–437. doi: 10.1111/j.1600-0447.1994.tb01620.x.CrossRefPubMedGoogle Scholar
  46. Powers, M. B., Vording, M. B. Z. V. S., & Emmelkamp, P. M. G. (2009). Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 78(2), 73–80. doi: 10.1159/000190790.CrossRefPubMedGoogle Scholar
  47. Rao, U., Hammen, C., Ortiz, L. R., Chen, L. A., & Poland, R. E. (2008). Effects of early and recent adverse experiences on adrenal response to psychosocial stress in depressed adolescents. Biological Psychiatry, 64(6), 521–526. doi: 10.1016/j.biopsych.2008.05.012.CrossRefPubMedCentralPubMedGoogle Scholar
  48. Reynolds, W. M. (2002). Reynold’s adolescent depression scale-2nd Edition: Professional manual. Lutz, FL: Psychological Assessment Resources.Google Scholar
  49. Reynolds, W. M. (2010). Reynolds Adolescent Depression Scale. In I. B. Weiner & W. E. Craighead (Eds.), The corsini encyclopedia of psychology. Hoboken, NJ: Wiley.Google Scholar
  50. Rosenthal, R., & Rosnow, R. L. (1991). Essentials of behavioral research: Methods and data analysis (2nd Ed.): New York, NY: McGraw-Hill.Google Scholar
  51. Rosnow, R. L., Rosenthal, R., & Rubin, D. B. (2000). Contrasts and correlations in effect-size estimation. Psychological Science, 11(6), 446–453. doi: 10.1111/1467-9280.00287.CrossRefPubMedGoogle Scholar
  52. Statistics Sweden. (2010). Undersökningarna av barns levnadsförhållanden [The surveys of children’s living conditions]. Pressrelease from SCB 16/08/10. No. 2010:209: Retrieved from Statistics Sweden:
  53. Theodore-Oklota, C., & Orsillo, S. (2011). A mindfulness-based program aimed at reducing the impact of relational aggression. Paper presented at 2011 Association for Contextual Behavioral Science Annual World Conference 9, Parma, Italy.Google Scholar
  54. Verbeke, G., & Molenberghs, G. (2000). Linear mixed models for longitudinal data. New York, NY: Springer.Google Scholar
  55. Wackerly, D., Mendenhall, W., & Scheaffer, R. L. (2008). Mathematical statistics with applications (7th ed.). Belmont, CA: Thomson Learning.Google Scholar
  56. Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain. A randomized controlled trial. Pain, 141(3), 248–257. doi: 10.1016/j.pain.2008.11.006.CrossRefPubMedGoogle Scholar
  57. Wilson, K. G., & Murrell, A. R. (2002). ACT for LIFE (Lifting Individuals for Future Endeavors): A treatment manual for at-risk youth. Retrieved from Association for Contextual Behavioral Sciences website:
  58. World Health Organization. (2011). Young people: Health risks and solutions. (Fact sheet No. 345). Retrieved from World Health Organization website:
  59. World Medical Association. (2008). Declaration of Helsinki: Ethical principle for medical research involving human subjects. Retrieved from

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Fredrik Livheim
    • 1
    • 2
    Email author
  • Louise Hayes
    • 3
  • Ata Ghaderi
    • 4
  • Thora Magnusdottir
    • 5
  • Anna Högfeldt
    • 5
  • Julie Rowse
    • 6
  • Simone Turner
    • 6
  • Steven C. Hayes
    • 7
  • Anders Tengström
    • 1
  1. 1.Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
  2. 2.StockholmSweden
  3. 3.Orygen Youth Health Research Centre, Centre for Youth Mental HealthUniversity of MelbourneParkvilleAustralia
  4. 4.Division of Psychology, Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
  5. 5.Department of PsychologyUppsala UniversityUppsalaSweden
  6. 6.Ballarat Health ServicesBallaratAustralia
  7. 7.Department of PsychologyUniversity of NevadaRenoUSA

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