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Journal of Contextual Behavioral Science 4 (2015) 111

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science


journal homepage: www.elsevier.com/locate/jcbs

Applications and adaptations of Acceptance and Commitment Therapy


(ACT) for adolescents
Amanda E. Halliburton n, Lee D. Cooper
Virginia Polytechnic Institute and State University (Virginia Tech), 109 Williams Hall, Blacksburg, VA 24060, USA

art ic l e i nf o

a b s t r a c t

Article history:
Received 27 June 2014
Received in revised form
22 December 2014
Accepted 19 January 2015

Acceptance and Commitment Therapy (ACT) is an emerging cognitive-behavioral therapy that uses mindfulness, acceptance and other skills to treat psychological problems. ACT differs from traditional cognitivebehavioral therapy (tCBT) in some ways, but the two therapies share several similarities. Though ACT has some
empirical support when used with adults, there is very sparse literature to date on using ACT with adolescents.
This review will discuss the state of the eld with regard to using ACT with adolescents with a special focus on
developmental adaptations and considerations that could enhance cognitive-behavioral treatment of this
population. Ten studies that utilized multiple or all ACT components with adolescents are the focus of this
review. The review will explore adaptations that are currently used in ACT research with adolescents, considerations that have been suggested but were not implemented in these studies, and other adolescent problems
that could potentially be ameliorated with the use of ACT techniques. The review will conclude with a discussion of salient methodological and assessment-related limitations, suggestions for choosing whether ACT might
be appropriate for use with adolescent clients, and ideas for future research on using ACT with adolescents.
& 2015 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

Keywords:
Acceptance and Commitment Therapy
Adolescents
Treatment adaptations
Child development

Contents
1.
2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The ACT treatment process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Contact with the present moment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.
Defusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4.
Self as context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.
Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6.
Committed action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. The effectiveness of ACT and comparisons to tCBT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Using ACT components and processes with adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Building a developmentally sensitive treatment protocol for adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.
Adaptations based on biological development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2.
Adaptations based on psychological development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.
Adaptations based on social development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Other suggested developmental considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Other hypothetical applications of ACT for adolescent problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Methodological and assessment considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. Future research directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Corresponding author. Tel.: 1 757 409 0062.


E-mail address: ahallibu@vt.edu (A.E. Halliburton).

http://dx.doi.org/10.1016/j.jcbs.2015.01.002
2212-1447/& 2015 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

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A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

1. Introduction
In recent years, some basic tenets and processes of traditional
cognitive-behavioral therapy (tCBT) have been the subject of
debate among psychotherapists and clinical researchers (Hayes,
Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). In particular,
there have been questions about whether thought content needs
to be targeted (Hayes, 2004). Additionally, some nd it troublesome that common cognitive techniques cannot be scientically
linked to basic cognitive psychology (Hayes, Luoma, Bond, Masuda,
& Lillis, 2006) or worry that tCBT is too symptom-focused
(Hofmann & Asmundson, 2008). Change sometimes occurs before
the relevant tCBT techniques are introduced, and there is unclear
support for proposed mediators of change (Longmore & Worrell,
2007), like coping skill development (Morganstern & Longabaugh,
2000) or dysfunctional attitude changes (Burns & Spangler, 2001).
New styles of cognitive-behavior therapy have emerged in
response to these critiques, one being Acceptance and Commitment Therapy, or ACT (Hayes, Strosahl, & Wilson, 1999). Generally speaking, these therapies take a contextual approach, with
the goal of helping clients respond to the function rather than the
content of thoughts (Hayes, 2004). Context becomes problematic
when clients desire to control, explain, or otherwise cope with the
thought rather than simply experience it (Hofmann & Asmundson,
2008). These therapies promote greater mindfulness and thought
acceptance instead of direct challenging of thoughts, as in tCBT
(Hayes et al., 2013).
The following review will focus on ACT and its relevance and
application for clinicians who work with adolescents. In particular,
the review will discuss similarities and differences between an
ACT approach and a tCBT approach and provide suggested guidelines for determining which approach might be a better t for
individual adolescent clients. Special attention will be paid to
identifying developmental adaptations and considerations, drawn
from various cognitive-behavioral approaches that can facilitate
the use of ACT and other therapies with adolescents. Studies that
have used an ACT approach and incorporated these ideas will be
highlighted. Finally, salient methodological concerns and potential
solutions will be discussed.

2. The ACT treatment process


ACT centers on the problem of psychological inexibility, the
impact of which increases as people become dependent on
familiar control strategies for dealing with unpleasant experiences
without realizing that these apparent solutions are ultimately
ineffective (Hayes et al., 1999). In ACT, clients work on increasing
contact with the present moment and accepting problematic
thoughts or feelings rather than attempting to control or avoid
them. Clients practice disentangling their thoughts, feelings, and
behaviors and viewing themselves as separate from their problems. Clients also identify their values and practice engaging in
behaviors that work in service of those values, thus moving their
lives in more of a valued direction (Hayes et al., 2006). The specic
techniques and processes utilized in ACT will each be discussed
now in more detail.

remove good and bad labels. In doing so, they reduce the
perceived power of feared stimuli. Though tCBT also uses selfmonitoring of experiences, ACT differs in that clients are not asked
to categorize, count or analyze their experiences, just notice them.
2.2. Acceptance
Acceptance involves engaging in mindfulness without attempting to interact with thoughts. In taking an acceptance stance,
clients end the struggle with thoughts and feelings without having
to change or eliminate them (Hofmann & Asmundson, 2008).
Together, the therapist and client examine the workability of prior
control behaviors and attempts to change thoughts or feelings, and
the client is shown that controlling automatic thoughts and
feelings is impossible (Hayes, 2004). Exposure exercises are used
in both tCBT and ACT to reduce avoidance, though symptom
reduction is not a goal in ACT (Hayes, Follette, & Linehan, 2004).
2.3. Defusion
Defusion is used to weaken the link between the verbal content
of thoughts and feelings and their function. Defusion techniques
promote a neutral perception of internal events (Springer, 2012),
allowing for greater variability in perceived possible responses.
The believability of private events is reduced despite thought
recurrence (Hayes et al., 2006). Defusion aims not to challenge
thought content, as in tCBT, but instead to alter the client's
interactions with and assumptions about the thought and allow
it to be experienced exibly.
2.4. Self as context
ACT encourages clients to move from the conceptualized self,
who is built by specic dening attributes, to the observing self,
who takes in experiences as a separate entity (Hayes et al., 1999).
The observing self is a separate being who experiences many
thoughts, feelings and behaviors but is not dened or dominated
by any of them; while experiences may change, the conscious,
observing self is constant (Hayes, 2004). Instead of targeting
individual dening or threatening thoughts, ACT self as context
work broadly targets many such internal experiences, evaluating
them on how they help or hinder the client's workability for
general functioning.
2.5. Values
Values are not meant to be reached nor fullled but instead are
used to continually guide behavior and choices about the best
directions in which to take a person's life. It is extremely important
that values be freely chosen and not selected based on societal or
family expectations, as feeling persuaded to live according to
certain values carries the risk of a return to the conceptualized
self (Hayes et al., 1999). Though the client once lived in service of
his or her symptoms or stressors, now his or her life will be guided
by values. tCBT may use values to help a client nd motivation, but
in ACT values are an explicit part of the treatment process.
2.6. Committed action

2.1. Contact with the present moment


ACT aims to increase contact with the present moment in a
process known as mindfulness (Hayes, 2004). Mindfulness
involves being aware of external and internal stimuli. ACT emphasizes that mindful contact should be nonjudgmental, ongoing,
exible, focused, and voluntary (Hayes et al., 2013). By simply
observing thoughts, clients learn to treat all events equally and to

Committed action operationalizes the values clarication process and begins the journey of value-directed living. The process of
committed action naturally invites the chance to face and overcome obstacles to value-directed living, such as pain or difculty
that must be accepted in order to move forward and prevent it
from determining the course of the client's life (Hayes et al., 2004).
The client is not committing to success in the process of pursuing

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

value-directed living; he or she is committing to move forward in


an unending process of attempting to make choices guided by his
or her values (Hayes et al., 1999). Committed action is reminiscent
of tCBT, with its analogous process of behavioral activation
(Hofmann & Asmundson, 2008).

3. The effectiveness of ACT and comparisons to tCBT


ACT has been found to be more effective than control conditions,
including waitlist controls, treatment as usual (TAU), and placebos
(Powers, Zum Vrde Sive Vrding, & Emmelkamp, 2009). Across
adults, children and adolescents, ACT is thought to be probably
efcacious for chronic pain and tinnitus, and possibly efcacious for
stress, weight problems, substance use disorders, anxiety disorders,
psychotic disorders, and depression (st, 2014). In addition, brief ACT
interventions seem to be no less effective than long-term ACT (Powers
et al., 2009). As noted earlier, there have been questions raised about
the process and mediators of tCBT, such as whether thought content
needs to be targeted, whether tCBT can be linked to cognitive
techniques, and what mediators facilitate improvement in tCBT
(Hayes, 2004; Hayes et al., 2006). The literature directly comparing
the outcomes and methodological design choices of studies on tCBT
and ACT is very mixed, particularly because of methodological
disagreements (e.g., Gaudiano, 2009; Levin & Hayes, 2009; st,
2009; Powers & Emmelkamp, 2009) and, as of now, evidence does
not suggest that ACT can outperform established therapies, including
tCBT (Powers et al., 2009). Despite these controversies, there are basic,
notable similarities and differences between tCBT and ACT that are
highlighted here for the purpose of comparison.
Both treatments have a cognitive component; ACT primarily
uses defusion and acceptance and tCBT uses cognitive restructuring. Both tactics create distance between the thought and the
person, be it distance from assuming the thought is a fact (tCBT) or
distance from the content of the thought (ACT; Longmore &
Worrell, 2007). tCBT is more focused on thought content, and
ACT focuses on a person's reaction to the thoughts and thought
functions (Herbert & Forman, 2013).
Both tCBT and ACT enhance anticipation and regulation of
emotion by teaching new ways to react to emotional experiences,
although ACT claims to not strive for control of the relevant
thoughts and emotional experiences (Arch & Craske, 2008). Thus,
both therapies work on antecedents of emotion: tCBT teaches
clients to proactively cope with thoughts that contribute to
negative emotion and ACT focuses on reducing anticipatory emotional distress by encouraging clients not to avoid or try to control
aversive thoughts (Herbert & Forman, 2013). ACT also directly
works on responses to emotion by teaching mindfulness and
acceptance, helping clients form healthy reactions to thoughts
(Brown, Gaudiano, & Miller, 2011).
The theoretical stances of tCBT and ACT also differ. ACT focuses
on the workability of strategies and psychological exibility by
encouraging clients to give up control and coexist with problematic thoughts and emotions, and tCBT emphasizes critical rationalism and socratic questioning of assumptions, leading clients to
doubt the validity of thoughts and feelings they were once
convinced were true (Hofmann & Asmundson, 2008).
Given these similarities and differences, some authors conclude
that there is no true third wave (Hofmann, Sawyer, & Fang, 2010),
others say that ACT is a signicant improvement over tCBT (Ruiz,
2012), and still others suggest compromising and pulling useful
components from both traditions (Herbert & Forman, 2013). Recent
studies comparing the treatments conclude that not enough is
known about mediators of treatment (Burns & Spangler, 2001;
Herbert & Forman, 2013; Hofmann & Asmundson, 2008). Possibly,
tCBT and ACT operate with different pathways but the same

mediators (e.g., metacognitive awareness; Yovel, Mor, & Shakarov,


2014), one approach uses the mediators more effectively (Ruiz, 2012),
or mediational processes depend on differing needs found within
individual clients and situations.
As suggested previously, ACT has been used effectively with adults
with a variety of diagnoses, among them depression (Zettle, Rains, &
Hayes, 2011), psychosis (Bach & Hayes, 2002), substance use disorders
(Luoma, Kohlenberg, Hayes, & Fletcher, 2012), and anxiety disorders
(Codd, Twohig, Crosby, & Enno, 2011). However, fewer outcome data
are available regarding the application of ACT to adolescents. In
addition to questions about whether these same disorders could be
treated successfully with ACT when presented by adolescents, there is
a need for a greater understanding of how ACT could be feasibly
applied to a younger population. The paragraphs to come will explore
these issues and discuss the current state of this literature.

4. Using ACT components and processes with adolescents


Some processes similar to those used in ACT have previously been
implemented with adolescents, suggesting that ACT could be adapted
for use with this population. Mindfulness-based stress reduction has
been used to lower anxiety and somatic distress and increase selfesteem and sleep quality in teens (Biegel, Brown, Shapiro, &
Schubert, 2009). Ames, Richardson, Payne, Smith and Leigh (2014)
found that mindfulness-based cognitive therapy reduced depressive
symptoms in adolescents. Mindfulness has also been used to
decrease the frequency of aggressive behaviors in youth with Autism
Spectrum Disorder (ASD; Singh et al., 2011) and improve attention
and cognitive inhibition in adolescents diagnosed with Attention
Decit/Hyperactivity Disorder (ADHD; Zylowska et al., 2008).
Acceptance-based therapies have also become popular to use
with adolescents. Acceptance-based techniques were used to treat
adolescents with cystic brosis and, as a result, the participants
had fewer depressive symptoms and experienced improved functioning in several domains (e.g., emotional, social; Casier et al.,
2011). Teenagers with chronic pain who underwent acceptancebased therapy had decreased anxiety and increased school attendance (Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013).
Adolescents with trichotillomania were given acceptanceenhanced behavior therapy, resulting in abstinence from hair
pulling and reportedly reduced distress (Fine et al., 2012).
Theodore-Oklota, Orsillo, Lee, and Vernig (2014) used an
acceptance-based protocol with teens who engaged in relational
aggression and found that treatment participants used problemsolving skills more often than controls at follow-up.
Luciano, Ruiz, Vizcano Torres, Snchez Martn, Gutirrez
Martnez, and Lpez Lpez, (2011) implemented a defusion protocol
similar to those used in ACT. The intervention was conducted with
adolescents at risk for a variety of behaviors. Defusion exercises
included awareness of breathing, neutral thoughts, and problematic
thoughts (e.g., anger). Participants reported engaging in fewer
problematic behaviors after treatment, having greater psychological
exibility, and experiencing greater acceptance without judgment.
The nal two ACT processes, values and committed action, have
been the focus of a few studies with adolescents. A study of
adolescents with ADHD and learning disorders revealed a relationship
between engagement in experiential avoidance and reports of valueinconsistent behavior (Murrell & Kapadia, 2011). The brief treatment
for adolescents with chronic pain conducted by Gauntlett-Gilbert et al.
(2013) also included a values component, though specic details about
this component and results specically tied to changes in values
awareness and congruence were not discussed in the article.
As mentioned previously, the literature on using ACT with
adolescents is still quite young. However, several studies have
been conducted that implemented full ACT protocols with

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

Table 1
Characteristics of studies that used ACT with adolescents.
Sample
size

Outcome measures

Primary ndings

Dissertation Full ACT

Self-reported daily
compulsion frequency; CYBOCS; CDI; MASC; COIS-R

Signicant reductions in primary (and sometimes


secondary) compulsions; CY-BOCS scores improved

Group treatment

Dissertation Full ACT

AFQ-Y; VLQ-A; BSI

Signicant increase in value-congruent living;


signicant correlations between psychological
exibility changes and symptom frequency report
changes

Hayes et al.
(2011)
Depression

Group pilot study

Peerreviewed

Full ACT

30

RADS-2; SDQ

ACT group showed greater improvement on RADS-2


scores compared with TAU group, with improvements
continuing into follow-up; both groups improved on
SDQ, with 26% of ACT group and 0% of TAU group
reliably improved at post-treatment

Heffner et al.
(2002)
Anorexia
Nervosa

Case study

Peerreviewed

Full ACT

EDI-2

Goal weight exceeded at follow-up; EDI-2 drive for


thinness and ineffectiveness scores improved at posttest

Livheim et al.
(in press)
Depression
(Australia);
Stress
(Sweden)

PeerTwo pilot studies


(planned comparison in reviewed
Australia and RCT in
Sweden)

Full ACT

51
(Australia);
32
(Sweden)

RADS-2; AFQ-Y8 (Australia);


PSS; DASS-21, SWLS; GHQ12; AFQ-Y17; MAAS
(Sweden)

Australia: ACT participants improved signicantly on


RADS-2 scores and improved somewhat, though nonsignicantly, on AFQ-Y scores; Sweden: ACT
participants improved signicantly on PSS scores,
improved non-signicantly on DASS-21 Anxiety
subscale scores, and improved non-signicantly on
MAAS scores

Myles (2002)
Disruptive
behavior
disorders

Multiple-baseline
single-case design

Thesis

Full ACT

Parent-reported behavior
monitoring; ECBI; SDQ;
AAQ; BDI-II

Decreases in disruptive behavior (e.g., arguing, noncompliance, verbal or physical aggression) from
baseline to post-treatment

Sabaini (2013)
Disruptive
behavior
disorders
(varied
diagnoses)

Pre-post quasiexperimental design


(with matched
comparison group)

Thesis

Full ACT

18

AAQ-II; AFQ-Y; grade point


average; attendance; good
behavior points

Slight decrease on AAQ-II and AFQ-Y scores for


treatment group (8% and 1%, respectively) compared
with score increase for comparison group (18% and
22%, respectively); GPA for treatment group increased
by 46% from baseline, resulting in a 48% higher GPA
than the comparison group; 20% increase in
attendance from baseline for treatment group, for an
average of 10% higher attendance than comparison
group; trend of increase in good behavior points

Wicksell et al.
(2005)

Case study

Peerreviewed

Full ACT

FDI; achievement of values- Increased functioning; substantial improvement in


self-reported valued living; increased school
based goals; school
attendance
attendance

Wicksell et al.
(2009)
Chronic pain

RCT

Peerreviewed

Acceptance
and
Exposure

32

FDI; pain interference score; Acceptance/exposure group performed better than


PAIRS; SF-36
control group (MDST) on all measures, with large
effect sizes

Woidneck
(2012)
PTSD

Nonconcurrent
multiple baseline
single-case design

Dissertation Full ACT

Self-monitoring of PTSD
symptoms (frequency,
distress, interference)

Citation/
diagnosis

Study design

Study type

Armstrong
(2011)
OCD

Nonconcurrent
multiple baseline
single-case design

Cook (2008)
Highfunctioning
ASD;
nonverbal
learning
disorder

Treatment
approach

Chronic pain

Six out of seven participants no longer met clinical


criteria for PTSD (one participant left treatment
prematurely)

Note: CY-BOCS: Children's Yale-Brown Obsessive Compulsive Scale; CDI: Children's Depression Inventory; MASC: Multidimensional Anxiety Scale for Children; COIS-R: Child
Obsessive-Compulsive Impact ScaleRevised; AFQ-Y/AFQ-Y8/AFQ-Y17: Avoidance and Fusion Questionnaire for Youth; VLQ-A: Valued Living Questionnaire for Adolescents;
BSI: Brief Symptom Inventory; RADS-2: Reynolds Adolescent Depression Scale2; SDQ: Strengths and Difculties Questionnaire; EDI-2: Eating Disorders InventoryTwo;
PSS: Perceived Stress Scale; DASS-21: Depression, Anxiety, and Stress Scale; SWLS: Satisfaction with Life Scale; GHQ-12: General Health Questionnaire; MAAS: Mindful
Attention Awareness Scale; ECBI: Eyberg Child Behavior Inventory; AAQ/AAQ-II: Acceptance and Action Questionnaire, Version Two; BDI-II: Beck Depression Inventory,
Second Edition; FDI: Functional Disability Inventory; PAIRS: Pain Impairment Relationship Scale; SF-36: Short Form-36 Health Survey.

adolescents. These studies, which are the major focus of this


review, will now be discussed in the context of the developmental
modications they selected to maximize their participants' gains.

5. Building a developmentally sensitive treatment protocol for


adolescents
Multiple scholars have called for more integration of adolescent
development research with treatment protocols for adolescents

(Steinberg, 2002; Weisz & Hawley, 2002). Some ideas for useful
adaptations and considerations, drawn from a collection of studies
that used most or all components of ACT as well as reviews of
other cognitive-behavioral treatment protocols that have been
implemented with adolescents (e.g., tCBT, Dialectical Behavior
Therapy (DBT)), will be discussed in the paragraphs to come.
These adaptations and considerations span several domains of
adolescent development (biological, psychological, and social) and
can be used broadly to augment the use of cognitive-behavioral
strategies with adolescents. Creative methods for implementing a

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

developmentally-minded treatment with adolescents that


emerged among ACT studies in particular will be highlighted
where applicable. This discussion is divided into three parts. First,
we include a review of adaptations suggested generally for
adolescent treatment that have actually been put into place by
studies that used ACT with adolescents. Next, there is an examination of other adaptations and considerations that have been noted
in prior child and adolescent treatment literature but were not
incorporated specically in the designs of the studies in this
review. Finally, a discussion is provided about other normative
struggles in adolescent development that could hypothetically be
ameliorated using ACT components.
For this review, ACT studies were gathered from a variety of
journals and disciplines. Adolescents were operationally dened
as children between the ages of 11 and 17. Search terms included
combinations of adolescents, ACT, Acceptance and Commitment Therapy, and ACT components (e.g., mindfulness, cognitive defusion). Studies that specically utilized multiple or all
components of ACT will be highlighted in this review. Also, several
studies that proposed ACT treatments were discovered as part of
the search, and their rst authors were contacted in order to
assess the status of the projects and obtain any preliminary
results. However, none of these authors were able to provide
updates and, as a result, these studies will not be included in this
review. In total, 10 studies that used a comprehensive ACT protocol
were selected for inclusion; individual details of these studies can
be found in Table 1.
Due to the fact that research on using ACT with adolescents has
only recently begun to develop, the group of selected studies
included both peer reviewed research and theses and dissertations. Thus, it is important to recognize that non-peer reviewed
research will be more useful when related peer-reviewed studies
that support their ndings become available in the future. Most
studies used single-case or group designs, with the exception of
one randomized controlled trial (RCT; Wicksell, Melin, Lekander, &
Olsson, 2009). Additionally, most studies used a combination of
process- and outcome-oriented measures in evaluating treatment
success, though others focused directly on symptom measures
(e.g., Armstrong, 2011; Heffner, Sperry, Eifert, & Detweiler, 2002;
Woidneck, 2012). Studies were drawn from multiple countries,
including the United States (US), Sweden, and Australia.
The studies in this review demonstrated that ACT and its
components can be helpful for adolescents with obsessivecompulsive disorder (OCD; Armstrong, 2011), autism spectrum
and learning disorders (Cook, 2008), depression (Hayes, Boyd, &
Sewell, 2011; Livheim et al., in press), anorexia (Heffner et al.,
2002), stress (Livheim et al., in press, disruptive behavior disorders
(Myles, 2002; Sabaini, 2013), chronic pain (Wicksell, Dahl,
Magnusson, & Olsson, 2005; Wicksell et al., 2009), and posttraumatic stress disorder (PTSD; Woidneck, 2012). Participants in
all studies experienced symptom improvement to varying degrees
and, in some studies, participants also reported experiencing
improvements on measures of functioning (e.g., grade point
average, school attendance; Hayes et al., 2011; Sabaini, 2013;
Wicksell et al., 2005, 2009). Additionally, participants in several
studies experienced change to varying degrees on ACT process
variables, including increased mindfulness (Livheim et al., in
press), increased psychological exibility (Cook, 2008; Sabaini,
2013), reduced avoidance and fusion (Livheim et al., in press;
Sabaini, 2013), and improved values-based living and congruence
(Cook, 2008; Wicksell et al., 2005).
5.1. Adaptations based on biological development
Behavioral activation is especially important for keeping adolescents engaged in sessions (Hayes, Bach, & Boyd, 2010; Wicksell

et al., 2005). Adolescents may have a lot of energy compared to


older clients, and it is benecial to utilize that energy in constructive ways during the session rather than attempt to suppress
it. Greco, Blackledge, Coyne, and Ehrenreich (2005, p. 310) recommend that session exercises for adolescents be as interactive and
experiential as possible. For example, concrete tools could be
used to allow adolescents to engage with cognitive metaphors
behaviorally (e.g., using a chessboard to illustrate the chessboard
metaphor; Heffner et al., 2002). The use of exposure exercises also
invokes this suggestion, though how these exercises are performed depends on the adolescent's level of independence and
level of progress in treatment thus far (Kingery, Roblek, Suveg,
Grover, Sherrill, & Bergman, 2006). Other ideas for in-session
activities include drawings, workbooks, presentations, role plays,
writing on an erasable board, and more (Kingery et al., 2006).
Thus, there are a wide variety of possibilities for implementing
behavioral activation, depending on the activity's purpose and the
adolescent's personality and readiness to participate in the
activity.
5.2. Adaptations based on psychological development
Recent work has supported Piaget's assertion that symbolic
reasoning begins to develop around age 11 (Peskin & WellsJopling, 2012). Skills related to creativity and insight are improved
and rened as adolescents get older, perhaps as a result of
increased knowledge about the world (Kleibeuker, De Dreu, &
Crone, 2013). Some practitioners have tried to use concrete tools
and strategies to improve adolescent comprehension of difcult or
abstract concepts in therapy. For example, mindfulness could be
tied to concrete activities such as eating or taking a walk (Zack,
Saekow, Kelly, & Radke, 2014). Other studies have permitted
clients to manipulate an actual Chinese nger trap during the
session while explaining acceptance in the context of the nger
trap metaphor (Armstrong, 2011; Heffner et al., 2002). Livheim
et al. (in press) utilized art as a concrete tool for exploring abstract
concepts. The use of art can also facilitate the cognitive defusion
process because it does not depend on the use of language,
including negative language that could inuence the adolescent's
perceptions of his or her experiences (Livheim et al., in press).
Other techniques for making difcult concepts more concrete
include allowing adolescents to write down their thoughts in
thought bubbles and providing a list of cognitive distortions to
guide cognitive restructuring (Kingery et al., 2006).
The use of age-appropriate language and examples can also be
helpful for enhancing adolescents' cognitive comprehension of
therapeutic processes. For example, negative thoughts could be
compared to unwanted pop-up advertisements, which are
familiar to adolescents who grew up with the use of the Internet
(Sauter, Heyne, & Westenberg, 2009). Wicksell et al. (2005), in
working with an adolescent who had chronic pain, conceptualized
her anxious thoughts as coming from a pain monster that told
her what she could and could not do because of chronic pain.
Developmentally relevant ACT metaphors that have been used
with adolescents include the passengers on the bus, tug of war
with a monster, a chocolate cake, and annoying party guest
(Armstrong, 2011; Cook, 2008; Myles, 2002; Woidneck, 2012).
Adolescent clients' own interests (e.g., sports, musical instruments, video games, hobbies) should be used to form the thematic
basis of activities and goals, build motivation for treatment, and
facilitate the outward generalization of novel skills (Kingery et al.,
2006). For example, when working with clients who have chronic
pain, it may be benecial to establish a hierarchy of physically
active goals (e.g., climb a ight of stairs) to guide the latter part of
therapy. From an ACT perspective, these goals can provide an
opportunity for the client to practice accepting and defusing from

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

pain-related anxiety while simultaneously making progress


toward values-based goals (Wicksell et al., 2005, 2009). The use
of clear behavioral goals also makes it easy to operationally dene
whether homework has been completed and goals have been
accomplished, thus facilitating an assessment of readiness for
discharge (Armstrong, 2011).

similar problems may positively affect their progress in treatment.


Additionally, it was noted that the use of a group setting may
facilitate implementation of similar programs in a school setting
by realistically depicting normative behavior dynamics and allowing for coping skills practice (Livheim et al., in press; Sabaini,
2013).

5.3. Adaptations based on social development


6. Other suggested developmental considerations
Parents are an important inuence to consider when treating
adolescents. It is important to be mindful of the adolescent's
maturity level and the parent's style (i.e., overly involved, not very
involved, or somewhere in between) when determining the role of
parents in treatment, which can range from being informed about
the adolescent's progress to assisting with skill practice at home
and even serving as co-clients with family- or parenting-related
problems that need to be addressed simultaneously with the
adolescent's presenting problems (Katz, Fotti, & Postl, 2009;
Sauter et al., 2009). Furthermore, parental expectations about
the outcome of treatment may need to be evaluated and reformulated so as to be more in line with the adolescent's expectation
and more reective of the realistic possibilities available with the
selected treatment (Kingery et al., 2006).
Some specic tasks that require parental involvement in DBT,
for example, include enhancing skills practice outside of session,
confronting problems that emerge between family members and
the adolescent client, and using family-focused dialectical dilemmas as tools (MacPherson, Cheavens, & Fristad, 2013). In their
study of an adolescent with chronic pain, Wicksell et al. (2005)
held separate sessions with the parents to discuss the workability
of their prior attempts at helping their daughter, their negative
avoidance of her symptoms, and the use of values to guide her
decisions. These sessions were meant to help the parents feel
comfortable coaching the client through treatment. Parental support was also cited as an important factor in treatment success in
the study of an adolescent with anorexia (Heffner et al., 2002).
Helping parents learn how to support their child has benets that
extend beyond treatment. Parental attachment is positively correlated with peer attachment, and perceived parental social support
has been linked with higher self-esteem, social competence, and
well being (Helsen, Vollebergh, & Meeus, 2000).
The inuence of peers becomes more prominent as adolescents
grow older. It is important to consider real-world settings that
feature peer interactions to which gains made in treatment need
to be generalized (Kingery et al., 2006). Group sessions can serve
the dual purpose of providing a more realistic opportunity to
practice these skills (in contrast to purely individual therapy) and
enabling the utilization of positive peer inuences to enhance
treatment for adolescents with relatively common problems
(Sauter et al., 2009). However, the adolescent's social competence
and comfort level with peer involvement must also be considered
carefully when determining whether or not to include peers in
treatment (Sauter et al., 2009).
Louise Hayes and colleagues have implemented group treatments for adolescent depression (Hayes & Rowse, 2008; Hayes et
al., 2011) and stress (Livheim et al., in press) and reported that the
group setting is helpful for building a sense of belonging and a
non-judgmental atmosphere. Furthermore, feedback on the group
setting indicated that participants in these studies liked knowing
that multiple members shared common problems (Livheim et al.,
in press). Peers can provide information to each other (i.e., ideas
for how to deal with difcult obstacles in therapy) and share
emotional
support
(Hombrados-Mendieta,
Gomez-Jacinta,
Dominguez-Fuentes, Garcia-Lieva, & Castro-Trav, 2012). Adolescents tend to thrive in environments where they feel that they t
in (Eccles & Roeser, 2011), and having a group of peers with

The onset of puberty is an important biological event that


typically coincides with the early stages of adolescence
(Blakemore, Burnett, & Dahl, 2010). Family conict and abuse have
been linked to early onset of puberty, particularly in girls (Short &
Rosenthal, 2008). In addition, early maturing girls and late maturing boys may be at a higher risk of demonstrating psychopathology, deviant behavior, and substance use later in life (Graber,
Seeley, Brooks-Gunn, & Lewinsohn, 2004). Thus, it is recommended that clinicians be mindful of reports from adolescents
and their parents about recent physical or emotional changes and
any associated distress that could become a salient treatment
target. In addition, it is important to consider the effects of any
potentially traumatic elements of the client's history on pubertal
development, in terms of monitoring the client for the development of troubling symptoms or other changes.
A signicant gain in white matter volume and myelination
occurs during adolescence, resulting in faster information processing (Paus, 2005). However, given that prefrontal and frontal
control are still developing during this period (Rubia et al.,
2006), adolescents may be guided by their emotions and at times
act more impulsively than adults (Hare, Tottenham, Galvan, Voss,
Glover, & Casey, 2008). Neural areas responsible for response
inhibition, risk and reward evaluation, and emotion regulation
undergo signicant change and growth during adolescence
(Steinberg, 2005). As a result of these ongoing neurocognitive
shifts, adolescents may benet from less cognitively intensive
treatment in terms of session number, session length, exibility
(e.g., who is part of the session, what activities are included) and
module complexity (Cosgrave & Keating, 2006; MacPherson et al.,
2013). It is important to consider adolescents' uctuating moods
and potential attention difculties when planning out didactics
and activities for a session. For example, prior studies of mindfulness with adolescents have suggested reducing the length of
mindfulness meditations (Biegel et al., 2009) in order to allow
adolescents to more gradually familiarize themselves with the
practice. Another option when using a shorter treatment is to
allow the adolescent to repeat the treatment in order to work
more on specic skills or areas of weakness, or to invite them to a
graduate group for other clients in the same age range who have
completed treatment and are working on maintaining their gains
(Katz et al., 2009).
Personal insight is another process that increases with cognitive development. As they develop more of an ability to relate the
present to the past and future, adolescents nd their own autobiographies more interesting, as evidenced by the popularity of
diaries (and perhaps by extension, blogs; Habermas & Bluck,
2000). Metacognitive abilities increase over adolescence, suggesting a growing capacity for self-reection and self-evaluation (Weil
et al., 2013) and a greater ability to analyze one's own thoughts,
emotions and behavior in a therapeutic setting. However, if
adolescent clients struggle with treatment, incorporating behavioral interventions can help reduce the reliance on cognitive
techniques and other insight-dependent processes. For example,
Murrell, Coyne, and Wilson (2005) suggested using a heart-shaped
box to represent the client's heart, which the client was instructed
to ll with slips of paper containing his or her vital values.

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

Motivation for treatment is an important issue to consider when


working with adolescents. This is especially true for adolescents who
do not acknowledge having problems that require therapeutic
intervention or for those who feel forced into treatment by their
parents, given that these attitudes can negatively impact the development of a good working alliance between the therapist and client
(Weisz & Hawley, 2002). It may be benecial to work with parents in
orchestrating special rewards for the adolescent's continued participation in treatment, which could take the form of tangible items (e.g.,
movie tickets, extra time to watch TV before bed, gift certicates to
favorite stores) or social rewards (e.g., having dinner out, inviting a
friend for a sleepover, or having protected time to engage in a
favorite activity with a parent; Kingery et al., 2006). However, care
must be taken to prevent such incentives from being viewed as
coercive (Hayes et al., 2011).

7. Other hypothetical applications of ACT for adolescent


problems
Adolescents often get involved in multiple activities (e.g.,
school, teams, clubs, community groups), which may create stress
and make focusing on everyday tasks difcult. Mindfulness training may help adolescents disengage from stressful thoughts and
focus on the present moment (Biegel et al., 2009) as well as
promote increased self-care and improved sleep (Wall, 2005),
thereby balancing out the negative effects of stress. Additionally,
participation in extracurriculars could be enhanced with a discussion of values, such that current recreational activities can reveal
interests and future goals (Eccles, Barber, Stone, & Hunt, 2003).
Autonomy seeking is a normative part of child development
and, as adolescents grow and enter puberty (Steinberg & Morris,
2001), they begin to desire more freedom and independence
(Steinberg & Silk, 2002). They may develop their own systems of
morals and values and ght back against their parents' rules
(Steinberg & Silk, 2002). Some adolescents may ght back against
their parents' rules, while others may feel uncomfortable acting
without close parental supervision (Van Petegem, Beyers,
Vansteenkiste, & Soenens, 2012). Acceptance could be an important tool in family therapy for resolving arguments about independence between parents and adolescents. Values could also be
utilized in this discussion in order to improve understanding of
both perspectives and facilitate decisions regarding parentchild
compromise.
During adolescence, the ability to recognize emotion in others'
faces increases, potentially causing social information to become
more salient as children enter adolescence (Paus, 2005). The onset
of puberty can inspire negative social comparisons among adolescents, who may be uncomfortable with their changing bodies and
sexual feelings (Steinberg & Morris, 2001). High levels of peer
pressure have been shown to decrease self-efcacy, particularly for
school performance (Kiran-Esen, 2012), suggesting a need to
confront it and reduce its effects. Acceptance techniques could
increase an adolescent's willingness to be exposed to unpleasant
thoughts or feelings related to resisting reckless behavior (e.g.,
thoughts related to using protection during sex even if pressured
not to do so; Metzler, Biglan, Noell, Ary, & Ochs, 2000). Mindfulness can be used to train attention and increase feelings of selfcontrol, leading to reductions in impulsive behavior (Thompson &
Gauntlett-Gilbert, 2008). Defusion and self as context work may be
helpful for breaking the mental connection between social labels
and personal identity, allowing for increased psychological exibility in dening the self. A discussion of values may explain why
an adolescent wants to engage in risky behavior and guide the
adolescent to make choices based on personal values rather than
current trends among peers.

The recent U.S. recession has implications that stretch to adolescents and emerging adults, including a need to nd a stable job and to
rely less on parents for monetary support (Danziger & Ratner, 2010).
Despite individual differences in nancial feasibility, many students
are being pressured to attend college (Gutman & Schoon, 2012).
Practicing mindfulness may reduce the harmful effects of stress on
the cardiovascular and hormonal systems (Broderick & Jennings,
2012). Mindfulness and acceptance strategies could also be used to
reduce anxiety related to achievement and career selection by
increasing psychological exibility and opening the way for valuesdirected decision-making (Greco et al., 2005). Values clarication can
be a good way to explore an adolescent's career aspirations and
formulate appropriate career goals.
Finally, adolescence is a critical period for identity formation
(Bosma & Kunnen, 2001). This process is affected by parental, peer
and community inuences (Beyers & ok, 2008). Minority adolescents, particularly those who immigrate with their families, have
the dual task of searching out a personal identity and integrating
their cultural values with those of the society in which they now
live (Crocetti, Rubini, Luyckx, & Meeus, 2008). Due to the rise of
emerging adulthood, older adolescents prolong the process of
identity exploration for much longer than people their age did in
previous generations (Arnett, 2000) and experience greater frustration and identity stress. Though some identity shifting is
common, continual shifts can lead to adverse clinical outcomes,
particularly internalizing problems (Klimstra, 2013). ACT has been
effective in reducing adult self-stigma related to substance use,
body weight, and internalized homophobia (Yadavaia & Hayes,
2012). Defusion and self as context work can reduce the pressure
to establish a single, solidied identity and make room for a
multifaceted life directed by values (Luoma, Kohlenberg, Hayes,
Bunting, & Rye, 2008). Mindfulness and acceptance could also
increase individual tolerance of identity stress (Lillis, Hayes,
Bunting, & Masuda, 2009).

8. Methodological and assessment considerations


As might be expected with a newly emerging literature, the
studies in this review cited some important limitations related to
methodology and assessment. The most commonly cited problems
were selected for special mention here in order to highlight their
importance for future studies in this area. However, it should be
noted that many of these limitations are not specic to the studies
in this review, ACT, or adolescent treatment but apply broadly to
clinical literature. The pervasive nature of these issues further
demonstrates the importance of overcoming them.
Several of the studies in this review cited small sample sizes as
a methodological limitation (e.g., Livheim et al., in press; Wicksell
et al., 2009). It is unclear whether this problem is specic to
adolescents in clinical distress or those in ACT-focused programs. If
specic to ACT research, this problem may reect the fact that
research on using ACT with adolescents is still fairly new and is
thus comprised mainly of single case designs and other small-scale
research. Other potential reasons for this problem, assuming it is
not specic to research on using ACT with adolescents, may
include the perception by some adolescents that they are being
forced into treatment or concerns about the helpfulness of the
therapist or treatment. Modications to the treatment protocol
may encourage adolescents to participate and facilitate their
retention. For example, in one study of adolescents with STDs,
the researchers minimized parental involvement to augment
participant condentiality, thus potentially encouraging adolescents to feel comfortable participating in the study (Metzler et al.,
2000). Hayes et al. (2011) suggested that clinicians interview
clients in the home or online to maximize convenience. Incentives

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

have been suggested and previously used as a method for retaining adolescents in treatment (Sabaini, 2013), though it is possible
that incentives could be deemed coercive (Hayes et al., 2011).
Sampling problems could also lead to difculty obtaining a
control group (Metzler et al., 2000). Problems with recruiting
heterogeneous samples have been noted (Coyne, McHugh, &
Martinez, 2011). Most participants across the studies in the review
were female, Caucasian, and from middle to high-income families,
limiting the generalizability of results. Convenience samples may
have been drawn from existing programs or schools, or perhaps
high-income participants were desired due to greater education
and apparently stronger cognitive abilities. To fully understand
ACT's breadth of applicability, sample diversity in future studies
will be key.
Ensuring treatment compliance also presented as a common
problem. Fidelity coding can reduce the likelihood of protocol
deviation, which may be especially important for research therapists who have been newly introduced to the use of ACT (Yadavaia
& Hayes, 2012). Researchers could also encourage participants to
complete at-home assignments by providing structured handouts,
setting small, achievable weekly goals, and asking participants to
share the results of their practice during the next session; sharing
results may have the additional benet in group settings of
assisting other group members who struggle with homework
(Hayes & Rowse, 2008). Parents, especially those who are given
psychoeducation about ACT in separate sessions, can also help
ensure between-session assignment completion and assist with
at-home skills practice. Additionally, it is important to rule out
alternative explanations for treatment successes. Factors to consider include rapport with the therapist (Woidneck, 2012), parental support (Heffner et al., 2002), time spent in therapy
(Gauntlett-Gilbert et al., 2013), education and training of the
participants or staff members (Sabaini, 2013) and participants'
downward social comparisons to others who are perceived to be
doing worse (Gauntlett-Gilbert et al., 2013).
Several studies noted limitations related to measurement, namely
that of using self-report surveys (e.g., Wicksell et al., 2009). Selfreport questionnaires provide meaningful information for clinicians,
especially with older, cognitively capable adolescents, but they can
also be unreliable and subject to social desirability. To overcome this
difcult problem, clinicians can use structured interviews (Swain,
Hancock, Dixon, Koo, & Bowman, 2013), gather observer reports
(Casier et al., 2011), or take physical or behavioral measurements
(Heffner et al., 2002) alongside self-report surveys. The measures
used must also demonstrate good psychometric properties, particularly when measures written for adults have been adapted for a
younger population. Reliability and validity issues were cited as a
limitation for outcome measures in several studies (e.g., Cook, 2008).
Notably, while there are many symptom measures that have
been adapted for children and adolescents, the process measures
commonly used in ACT with adults are only beginning to be
adapted for children. This represents a signicant measurement
issue for ACT research with adolescents because ACT does not
target symptom reductionit focuses instead on processes that
can be generalized beyond symptom complaints (Murrell &
Scherbarth, 2011). Some measures have been adapted, such as
the Avoidance and Fusion Questionnaire for Youth (Greco,
Lambert, & Baer, 2008) and the Social Values Survey (Blackledge
& Ciarrochi, 2006), but more are needed to allow a varied selection
of ACT measures for clinicians who work with youth.

9. Summary and conclusions


ACT emerged as part of the third wave of historical developments in cognitive and behavioral therapy traditions. It primarily

differs from its predecessor, tCBT, in the areas of cognitive


techniques (using defusion and acceptance as opposed to cognitive
restructuring), emotional coping (focusing on how to respond to
emotions with mindfulness and acceptance instead of focusing
only on the antecedents of emotion), and outcomes (emphasizing
workability of strategies and psychological exibility instead of
direct symptom reduction). However, ACT shares similarities with
tCBT in that both treatments fall under the umbrella of cognitivebehavioral therapies, both work to reduce reliance on ineffective
cognitive patterns, and both consider the fact that emotional
responses could potentially hamper effective decision-making.
ACT has been shown to be effective for several psychosocial
problems in adults when compared with control conditions,
including depression, chronic pain, and psychosis (Powers et al.,
2009). However, the literature on using ACT with adolescents
remains very limited. As suggested by this review, ACT shows
some promise for adolescents, may be applicable to their problems, and can take lessons from other cognitive-behavioral
therapies in adapting to adolescents' biological, cognitive, and
social needs. However, important methodological and assessment
problems have also been noted that will need to be addressed as
this area of research continues to grow, particularly given that they
do not seem unique to ACT studies.
As mentioned before, the literature on actually implementing
ACT with adolescents is relatively small and consists mostly of case
studies, small trials, and brief interventions. These studies suggest
that ACT may be effective for adolescents with chronic pain,
anorexia, depression, OCD, PTSD, stress, disruptive behavior disorders, learning disorders, and autism spectrum disorders. A
number of developmental adaptations were used in these studies
to make treatment more accessible and appropriate for adolescents, including increased behavioral activation, age-appropriate
examples, personalized goals, cognitive methods for explaining
abstract concepts, and the inclusion of parents and peers. These
adaptations are applicable not only to ACT but also to other
cognitive-behavioral therapies, such as tCBT and DBT. Also, other
developmental considerations and adolescent concerns that
related to ACT components in particular were suggested and
treatment strategies were discussed.
Continued research that explores the use of ACT with adolescents will better dene how to choose whether or not to implement an ACT approach with an adolescent client. Based on the
evidence discussed in this review, ACT may be most appropriate
for adolescents with apparently advanced insight capabilities and
abstract reasoning skills. On the other hand, adolescents who are
suited to a more concrete approach would likely gain more from
tCBT, given that it requires less complex abstract reasoning and
relies more on simplied cognitive tools and behavioral goals. The
choice of treatment may also depend on the themes that emerge
in discussing the presenting problem; for example, an adolescent
who reports difculties related to peer pressure and identity
confusion may benet from an approach that helps him or her
defuse from peer expectations and develop a more individualized,
values-directed set of goals for the future. Overall, clinicians
should use careful judgment in choosing appropriate treatments
for adolescent clients, and it is important to recognize that
treatments other than ACT (e.g., exposure and response prevention
for OCD) may be the best front-line solution for particular
adolescent problems. However, for disorders where evidence to
support the use of ACT with adults has been accumulated (e.g.,
chronic pain), it may be appropriate to consider using an ACT
approach.
To summarize, the current literature on using ACT and ACT
techniques with adolescents provides some guidance for translating
ACT protocols used with adults for a younger population and widening
the scope of their use. This process will require that the developmental

A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111

considerations and concerns related to methodology and assessment


discussed previously be recognized and addressed adequately. More
research is needed to fully understand how ACT can be used effectively
with adolescents and how to determine whether ACT, tCBT, or another
treatment approach is best suited to the presenting problems of
individual adolescent clients.

10. Future research directions


This review revealed that acceptance and mindfulness have
been utilized successfully with adolescents in several studies.
Other components and processes used in ACT have not yet been
implemented pervasively with adolescents. Only one study was
found that used defusion and self as context work with adolescents (Luciano et al., 2011). Also, few studies were found that used
values and committed action specically with adolescents. More
research on these components is needed to fully understand how
they could be used with adolescents.
ACT and its components have been utilized with adolescents who
have a variety of different problems, which is promising for the future
of ACT with adolescents. However, many questions about its applicability remain unanswered. There are other disorders experienced by
adolescents that could benet from ACT but have not yet been studied
adequately; as discussed previously, some disorders that have been
treated successfully in studies on the use of ACT with adults, and
replication with adolescent clients may become a future step in this
line of research. It is also unclear whether ACT could be implemented
with cognitively limited adolescent populations and, if so, how it could
be adapted to improve treatment success. The literature additionally
suggests that ACT could be used in prevention and community
programs and with diverse populations (e.g., Biglan, Hayes, &
Pistorello, 2008; Hathaway & Tan, 2009; Sobczak & West, 2013). Thus,
there are a number of new directions that researchers interested in
learning more about the use of ACT with adolescents might take, given
the nascent state of the literature.
Several methodological and assessment limitations were noted
across multiple studies. Furthermore, methodological problems have
been a major obstacle in current discussions about the effectiveness of
ACT compared with tCBT and other empirically supported treatments
(ESTs). The most frequently cited problems have been the exclusive
use of self-report measures, small samples, attrition, and lack of a
control or comparison group. These problems will need to be
addressed and overcome as information about the effectiveness of
using ACT with adolescents continues to come to light. More research
on the use of ACT with adolescents will benet service providers who
work with this population by suggesting new ways to treat adolescents or supplementing existing therapies. Furthermore, research with
larger, more diverse adolescent samples will provide valuable information about for which types of adolescents ACT could be a helpful
treatment option.

Acknowledgments
I thank my doctoral committee members, Dr. George Clum,
Dr. Kirby Deater-Deckard, and Dr. Bradley White, for their contributions and support in preparing this manuscript, which was
part of my preliminary exam. I also thank Neville Galloway-Williams,
M.S., for her help and encouragement in deepening my understanding of core ACT concepts.
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