Reducing Stress and Enhancing Academic Buoyancy among Adolescents Using a Brief Web-based Program Based on Acceptance and Commitment Therapy : A Randomized Controlled Trial

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Reducing Stress and Enhancing Academic Buoyancy among Adolescents Using a Brief Web-based Program Based on Acceptance and Commitment Therapy : A Randomized Controlled Trial © The Author(s) 2018 Published version Puolakanaho, Anne; Lappalainen, Raimo; Lappalainen, Päivi; Muotka, Joona; Hirvonen, Riikka; Eklund, Kenneth; Ahonen, Timo; Kiuru, Noona Puolakanaho, A., Lappalainen, R., Lappalainen, P., Muotka, J., Hirvonen, R., Eklund, K., Ahonen, T., & Kiuru, N. (2019). Reducing Stress and Enhancing Academic Buoyancy among Adolescents Using a Brief Web-based Program Based on Acceptance and Commitment Therapy : A Randomized Controlled Trial. Journal of Youth and Adolescence, 48(2), 287-305. https://doi.org/10.1007/s10964-018-0973-8 2019 Journal of Youth and Adolescence (2019) 48:287–305 https://doi.org/10.1007/s10964-018-0973-8 EMPIRICAL RESEARCH Reducing Stress and Enhancing Academic Buoyancy among Adolescents Using a Brief Web-based Program Based on Acceptance and Commitment Therapy: A Randomized Controlled Trial Anne Puolakanaho 1●Raimo Lappalainen1●Päivi Lappalainen2●Joona S. Muotka1●Riikka Hirvonen1● Kenneth M. Eklund3●Timo P. S. Ahonen1●Noona Kiuru1 Received: 26 September 2018 / Accepted: 29 November 2018 / Published online: 17 December 2018 © The Author(s) 2018 Abstract Acceptance and commitment therapy programs have rarely been used as preventive tools for alleviating stress and enhancing coping skills among adolescents. This randomized controlled trial examined the efficacy of a novel Finnish web- and mobile-delivered five-week intervention program called Youth COMPASS among a general sample of ninth-grade adolescents (n=249, 49% females). The intervention group showed a small but significant decrease in overall stress (between-group Cohen’sd=0.22) and an increase in academic buoyancy (d=0.27). Academic skills did not influence the intervention gains, but the intervention gains were largest among high-stressed participants. The results suggest that the acceptance and commitment based Youth COMPASS program may be well suited for promoting adolescents’well-being in the school context. Keywords Acceptance and commitment therapy ●Stress ●Academic buoyancy ●Adolescents ●Mobile intervention ● Randomized controlled trial Introduction Around 10–20% of adolescents in the West suffer from symptoms of stress, anxiety, and depression (Polanczyk et al. 2015; WHO 2014), which may hinder academic achievement (Cortiella and Horowitz 2014). However, individual factors, such as academic buoyancy, which refers to a student’s capacity to overcome everyday academic life setbacks and challenges successfully (Martin and Marsh 2009), may protect from the effects of psychological distress in the school context. New easily applicable methods are called upon to prevent and mitigate adolescents’ psychological distress and to support academic buoyancy, thereby potentially promoting adolescents’subsequent mental health and successful educational careers. In addition, intervention methods should work equally well for adolescents with poor academic skills and those with normally developing skills. There are a plethora of studies of adult populations showing that brief modern therapeutic methods and programs based on acceptance and commitment therapy are effective in the treatment of a variety of psychological conditions, including stress, depression, and anxiety (Flaxman et al. 2013; Hayes et al. 2012; Powers et al. 2009; Ruiz 2012). Moreover, a growing number of studies has used the acceptance and commitment approach in the treatment of adolescents, that is, 11–16-year-olds, for example, to alleviate depression (e.g., Petts et al. 2017), to alter behavioral outcomes (e.g., Armstrong et al. 2013), and to relieve physical conditions, such as pain (e.g., Wicksell et al. 2009). In general, acceptance and commitment approach based interventions for adolescents have shown positive effects in alleviating psychological symptoms, increasing quality of life, and enhancing psychological flexibility (Swain et al. 2015). However, studies in school settings are *Anne Puolakanaho anne.puolakanaho@jyu.fi 1Department of Psychology, University of Jyväskylä, P.O. Box 35, Jyväskylä 40014, Finland 2Department of Psychology and Gerocenter, University of Jyväskylä, P.O. Box 35, Jyväskylä 40014, Finland 3Faculty of Education and Psychology, University of Jyväskylä, P.O. Box 35, Jyväskylä 40014, Finland 1234567890();,: 1234567890();,: rare. Most of the previous studies have focused on clinical samples, that is, on participants who have significantly elevated psychological or physical symptoms or diagnosable disorders. In addition, in previous studies, the study designs and intervention programs have often been either poorly specified or included only some elements of the acceptance and commitment therapy protocol (Swain et al. 2015). Thus, due to previous research limitations, more information is needed on the usability of acceptance and commitment based interventions among adolescents in alleviating stress and promoting coping with academic setbacks in school settings. Over the last few years, new web- and mobile-based acceptance and commitment interventions have emerged and have been used successfully among adult participants (e.g., Lappalainen et al.,2014a; Lappalainen et al. 2014b; Lappalainen et al. 2015; Puolakanaho et al. 2018) and university students (Räsänen et al. 2016). It is likely that mobile-based interventions are also suitable for adolescents who are familiar with using modern technology in their everyday lives. However, no previous studies exist in which web- or mobile-based acceptance and commitment programs have been used with adolescents to enhance their stress coping. In contrast, interventions have hitherto been carried out in face-to-face meetings either individually or in groups. Consequently, the aim of this study was to examine whether the novel web- and mobile-based acceptance and commitment program influenced stress symptoms and academic buoyancy in the school setting in a general (nonclinical) sample of ninth-grade adolescents. In addition, the study examined whether the efficacy of the acceptance and commitment intervention differs based on whether an adolescent has poor academic skills. Applying the Acceptance and Commitment Model to Adolescents Acceptance and commitment therapy is described as a thirdwave cognitive therapy developed by Hayes et al. (1999), and it focuses on recognizing participants’own thoughts and emotions, as well as their connections to concrete behavior. More specifically, acceptance and commitment intervention models combine mindfulness and acceptance with behavioral principles and an understanding of personal values. Mindfulness refers to a state of consciousness in which attention is focused on present-moment phenomena, and acceptance refers to a willingness to experience all mental events (e.g., thoughts, emotions, and sensations) without changing, avoiding, or controlling them. Behavioral principles are used to clarify one’s personal values and to take actions that lead to goal accomplishment (Hayes et al. 2006; Hofmann and Asmundson 2008; Williams et al. 2008). Recent acceptance and commitment intervention models have aimed to reinforce the six core psychological processes: the ability to remain flexibly and purposefully in the present moment and to be mindful of thoughts, feelings, bodily sensations, and action potentials; keeping a perspective-taking attitude on thinking and feeling; clarifying one’s hopes, values, and goals in life; doing and cultivating things in line with identified hopes, values, and goals; willingly accepting unwanted feelings by taking actions that are consistent with one’s hopes, values, and goals; and increasing defusion skills, i.e., observing and recognizing one’s thoughts that interfere with experienced life events and valued actions and seeing them as thoughts rather than literal truths (Flaxman et al. 2013; Hayes et al. 2012). Each of these processes is a psychological skill that can be enhanced in any life domain with regard to unwanted internal experiences or symptoms (e.g., thoughts, feelings, and physical sensations). Therefore, acceptance and commitment interventions are thought to be a trans-diagnostic psychological treatments that potentially influences multiple psychologically derived symptoms and life issues (Dindo et al. 2017; Hayes and Hofman 2017). These theoretical views also suggest that acceptance and commitment interventions may also work as preventive and early tools in alleviating diverse psychological symptoms (here, stress) and promoting well-being and health (here, academic buoyancy). The above-mentioned acceptance and commitment approach principles can also be used for planning interventions for adolescents. However, many factors ought to be considered when devising programs for adolescents (Ciarrochi et al. 2012; Halliburton and Cooper 2015; Hayes and Ciarrochi 2015; see also Steinberg 2002). Adolescent Stress and Acceptance and Commitment Interventions Adolescents face multiple social, psychological, and physiological changes simultaneously in different life domains because of biological maturation, cognitive development, evolving sexuality, school transitions, and changes in social relationships, (e.g., Denham et al. 2009). In adolescence, conflicts with parents tend to increase and closeness with parents decreases as adolescents spend more time with their peers and come to value friendships more highly. Adolescents also face the challenges of learning to live independently and building their own social network by exploring and building their identities and starting romantic relationships (Steinberg and Morris 2001). At the same time, many adolescents experience stress in relation to school (e.g., Salmela-Aro et al. 2009; Seiffge-Krenke et al. 2012). Ninth-grade adolescents, who formed the target group of this study and who are finalizing their compulsory education, also face new personal and academic challenges because, for example, they have to 288 Journal of Youth and Adolescence (2019) 48:287–305 complete a great deal of school projects and have to clarify their interests to be able to choose their future educational path. All these issues may elicit stress and may even lead to burnout (Salmela-Aro 2017) and other mental health-related problems, such as substance abuse and self-harm behaviors, anxiety, and depression (Avison 2010; Dyson and Renk 2006). It is also well known that stress experiences at younger ages are related to various psychological symptoms and clinical disorders in adulthood (Lee et al. 2014; Liu and Alloy 2010; Mundy et al. 2015). Thus, there is a need for effective strategies to protect youth from the dysfunctional effects of stress. In an American survey, over 30% of teens reported being overwhelmed and depressed or sad due to stress (APA 2014). In a Swedish survey, 37% of girls and 22% of boys reported that they were frequently stressed (Wiklund et al. 2012). Similar trends have also been reported in a Finnish national school health survey (Finnish School Health Survey 2017), in which 32% of girls and 19% of boys reported serious schoolwork-related tiredness during the two last years of high school. Interestingly, the results of all these studies propose that girls are more likely than boys to experience stress (see also Wilhsson et al. 2016). These alarming figures call for novel and easily applicable methods to prevent and mitigate adolescents’stress and to support their coping skills. Some previous studies demonstrate that acceptance and commitment interventions can be effective in alleviating adolescents’stress. For instance, Burckhardt et al. (2016) conducted an intervention study that included elements from acceptance and commitment therapy and positive psychology in a sample of high school students (n=267, aged 16– 17 years) in Australia. In their study, significant changes with medium-to-strong effect sizes were observed in the stress scores of students who commenced the program with high stress, depression, and anxiety scores. Livheim et al. (2015) conducted a pilot study in school settings of adolescents who were screened for psychological problems in Australia (n=66) and Sweden (n=32). In their study, significant improvements in large effect sizes were reported for stress. In his earlier study, Livheim (2004) conducted an acceptance and commitment program for youth (n=230, aged 16–19 years), which revealed significant changes in stress and psychological flexibility that were also visible after two years. It is notable that the above-mentioned studies involved participants from clinical samples, that is, all the participants had elevated levels of psychological symptoms. Moreover, the interventions were implemented in face-to-face group settings and were led by trained counsellors. In contrast, no acceptance and commitment intervention results were found in a recent large-scale study conducted in school settings by teachers (Van der Gucht et al. 2017). Thus, although there is some evidence of the usefulness of acceptance and commitment interventions for adolescents, no previous study has used web or mobile technology to deliver the program individually to participants, which is the key topic of the current article. Adaptive Coping and Acceptance and Commitment Interventions There are wide individual differences among adolescents in their experiences of stress, as well as in how they respond to or cope with stress (APA 2014). Building capacity for academic buoyancy can help them cope with challenges in academic life. Academic buoyancy refers to a positive and optimistic attitude toward everyday academic setbacks and an ability to deal with such setbacks in the course of ordinary life (e.g., poor performance, competing deadlines, performance pressure, difficult tasks; Martin and Marsh 2009). Academic buoyancy has been shown to be negatively associated with psychological risks, such as school or text anxiety, and with a lack of self-efficacy (Martin and Marsh 2008,2009). Some theoretical frameworks have combined stress management and the promotion of coping skills (e.g., Haase 2004), and these frameworks have been further tested in adolescent interventions, usually among clinical samples (e.g., Rosenberg et al. 2015). However, due to the transdiagnostic nature of acceptance and commitment interventions and their proposed influence on deep psychological functions (e.g., Dindo et al. 2017; Hayes and Hofmann 2017), acceptance and commitment based exercises can be assumed to enhance adolescents’self-awareness and independence. These can be further expected to increase their coping skills, such as academic buoyancy in the current study, against stressors, as well as to alleviate experiences of stress. A recent study (Hirvonen et al. 2018) found that high levels of academic buoyancy were associated with a lower level of stress later in school. As such, buoyancy can be assumed a kind of counterforce against stress, although it has not been studied in the acceptance and commitment therapy context among adolescents. Poor Academic Skills and Acceptance and Commitment Therapy Poor academic performance may expose students to increased stress and psychological symptoms in comparison with better-performing students. A history of difficulties in learning and academic skills can lead, for example, to experiences of struggle, more conflicts with teachers and parents concerning homework, and increased negative emotions, such as frustration and disappointment in everyday learning situations (Cortiella and Horowitz 2014; Polanczyk et al. 2015). Consequently, it is possible that Journal of Youth and Adolescence (2019) 48:287–305 289 students with poor academic skills are particularly at risk for developing stress-related symptoms and could thus benefit from stress-reducing interventions. Yet, while some studies have noted that acceptance and commitment interventions may reduce psychological symptoms among students with academic challenges, there is little knowledge about whether acceptance and commitment interventions are similarly effective for students with different academic skill levels. Beauchemin et al. (2008) were able to improve the social and academic skills of adolescents with learning disabilities (n =34) through five weeks of mindfulness exercises carried out by their teacher. Tentatively positive effects have also been shown in samples involving learning disabilities and anxiety (Brown and Hooper. 2009). Interestingly, no study has examined whether students’academic skills moderate the efficacy of acceptance and commitment intervention in reducing stress and promoting academic buoyancy. This was one of the aims of the present study. Mobile and Web-based Interventions A substantial amount of psychological interventions utilizing new digital technology has been developed over the past few decades. Their usage is not restricted to place and time and they are usually cost effective. In addition, they can be used without a specific therapeutic background, and they can provide new insights for different professionals, such as teachers. According to Andersson and Titov (2014), digital interventions are considered as efficient as face-to-face therapies, especially when they include certain features, such as motivation aspects and personal therapeutic support (see also Wozney et al. 2017). Over the last few years, new web-based acceptance and commitment intervention programs have been developed among adults, which have been shown to be efficient in alleviating depression (Lappalainen et al. 2014a;Lappalainen et al. 2015) and work-related stress (Kinnunen et al. 2018) and in enhancing well-being (Lappalainen et al. 2014b). In a recent randomized controlled study, Räsänen et al. (2016) investigated the effects of a web-based acceptance and commitment program in a sample of university students (n =68; ages 19–32 years) with varying levels of psychological distress. They found medium-to-large effect sizes in several wellbeing measures. However, there is no study of adolescents (aged 12–16 years) in which an acceptance and commitment intervention based program has been used and delivered utilizing web and mobile technology. The Current Study The theoretical views presented above suggest that acceptance and commitment interventions may also work as preventive and early tools in alleviating diverse psychological symptoms (here, stress) and promoting well-being and health (here, academic buoyancy). In the current study, using the knowledge gained from new, complete acceptance and commitment intervention models for youth (e.g., Ciarrochi et al. 2012; Hayes and Chiarrochi 2015), a novel five-week web- and mobile-delivered intervention program called Youth COMPASS was developed. The main goal of the study was to explore the effects of the Youth COMPASS program on overall stress, school stress, and academic buoyancy among ninth-grade adolescents, who were in their last year of comprehensive school at the time of the study and therefore also vulnerable to stress-related experiences. The total sample of 249 adolescents was randomized into two acceptance and commitment intervention groups and a control group receiving only the usual support from the school. Half of the participants were identified as having poor academic skills. The current randomized controlled trial study addressed three main research questions. First, to what extent can ninth-grade adolescents’overall and school-related stress be reduced and academic buoyancy enhanced through the fiveweek web- and mobile-based acceptance and commitment intervention known as Youth COMPASS? Second, do the outcomes in the two intervention groups (which differed from each other slightly in the amount of personal face-to- face support) differ from each other regarding their efficacy, and do they differ from the control group’s outcomes? Third, do the adolescents’poor academic skills moderate the efficacy of Youth COMPASS in reducing adolescents’ stress and enhancing their academic buoyancy? Based on the acceptance and commitment view, the intervention was thought to enhance underlying psychological processes and, through them, different well-being experiences. Consequently, it was expected that the level of stress will decrease and academic buoyancy will increase more in the two intervention groups than in the control group. Because there are no previous studies on the influences of poor academic skills on acceptance and commitment intervention outcomes among youth, no hypotheses were proposed for the last question. Methods Study Design and Randomization The Youth COMPASS intervention study is part of the broader Stairway longitudinal research project, which aims to provide research-based knowledge of the individual- and environment-related factors that promote learning, well-being, and successful educational transitions. A subsample (n=249) of students from the broader longitudinal study (n~800, here 290 Journal of Youth and Adolescence (2019) 48:287–305 called the basic sample), carried out in two municipalities in Central Finland, were allocated for randomized controlled trials for the Youth COMPASS intervention. The interventions were carried out in the fall of the ninth grade (2017) before the transition to upper secondary school. The basic inclusion and exclusion criteria for study participation were set (see Fig. 1) before the selection and randomization. The selection of the target sample and its randomization into the intervention and control groups included two phases. In the first phase, two subsamples of adolescents from the larger basic sample (n~800) were selected. First, a group of adolescents with poor academic skills (n =125) (i.e., students who performed below the 16th percentile in reading or math tests during grades 6 and 7 [see a description of these tests in the Measures section] or students who belonged to the lowest 16th percentile in general academic achievement in their grade point average at the end of grade 7) was identified (see also Table 1). This cut-off definition identifies the same participants as a categorization defined as “1 deviation below the mean based on the sample normal variation”(see, e.g., Landerl et al. 2009). Second, a similarly sized group of adolescents with no signs of poor academic skills (n=124) was identified from the same classrooms as the participants with poor academic skills. In the second phase, the participants from these two groups (n =249) were further randomly allocated into three study groups by an independent researcher: the iACTface group, receiving both face-to-face and online support; the iACT group, receiving only online support; and the control group, receiving no additional support. Six of the randomized adolescents withdrew from the intervention or they could not be reached before starting the program, and no data were available for them. Thus, the final sample of this study consisted of 243 adolescents, 161 of whom took part in the Youth Compass intervention: 81 adolescents participated in the iACTface group and 80 in the iACT group. The control group consisted of 82 adolescents. Pre-data were available from 243 and post-data from 239 adolescents (see Flowchart, Fig. 1). Written consent for participation was obtained from both the adolescents and their parents during the spring of 2017. The participants’mean age at the beginning of the study was 15.27 years (SD =0.39), with P m D m Pa (n Di m Parti mea Did n mea artic = 8 id n eas All W E icip sur not sur cipa 81) not p sure loca What Enr pate rem pa rem ated par eme ated tsA roll ed in ment rtic ment d in rticip ent d to pp N lme n po t (n ipat t (n n pre pate (n o th sup = 8 ent ost- = 7 te in = 4 e-m e in = 2 e iA ppo 83 t - 77) n p 4) mea n pr ) ACT ort g P ostasur re- Tfac grou Pop - rem ce up Pop ula L ment pula tion Lon t atio n 2: ngitu p on 1 Ra udin parti : S and A Pa (n Did (n nal icip R tud om ac Allo artic = 8 d no = 2 Pa com patio P P Ran dent ly c cad cat cipa 80) ot p 2) artic mm on i Pos Pre ndom ts w cho em ted ted part cipa Par muni in th A st-m -m miz with sen mic s to t d in icip ated rtic ity s he Y Allo me mea zed 2 po n st skill the pre pate d in (n cipa sam You oca eas sur 2 (n or a ude ls (n iAC e-m e in pos n = ant f mple uth atio sur rem = 2 aca ents n = CT eas pre st-m 80) flow w CO on em me 249 adem s w 124 gro sure e-m mea ) w di (n = ith w OMP men ent 9) mic ith n 4) oup eme meas asu iagr = 43 writ PAS In nt c sk nor n = ent sure rem ram 3) tten SS nclu kills rma = 82 eme men m n co N~8 usio se (n ally d 2 ent nt onse 800 on a lect = 1 dev ent 0 and tion P ( D m 25) velo for ex n of Part (n = Did mea A Pa me ) ope r xclu the ticip = 82 not asu Allo artic eas d sion e ta pate 2) t pa rem ocat cipa sure n cr rge ed i artic men ted ated eme rite et po in p cipa nt (n to n d in ent ria 1 opu preate n = the n = po (n = for ulati -me in p 2) e co 84 ost- = 8 r the ion 1 easu preontro 2) e 1 urem - ol g me grou nt up Fig. 1 Flowchart. Note: The inclusion and exclusion criteria1 for the target population were as follows: Belonged to the larger longitudinal study basic group; had written consent for participating in the intervention; was a native Finnish speaker; and had previous data concerning reading and math skills and achievement scores from grades 6 and 7. Randomization2was conducted in two phases: First, an equal number of male and female adolescents with poor academic skills were identified. Second, an equal number of same-sex classmates who had normally developed academic skills were randomized into the study. All participants were randomly allocated into three study conditions by an independent researcher Journal of Youth and Adolescence (2019) 48:287–305 291 an almost equal number of boys (n=124; 51%) as girls (n=119; 49%). Demographic and sample characteristics at the baseline are provided in Table 2. Coaches In accordance with previous study recommendations (Andersson and Titov 2014; Wozney et al. 2017) and experiences in web-delivered interventions (e.g., Lappalainen et al. 2015; Räsänen et al. 2016), the participants received coaching and support from 31 acceptance and commitment approach -trained undergraduate psychology students (83% women). The coaches were students at the bachelor’s (41%) or master’s (59%) level. They received a total of 18 h of acceptance and commitment therapy training and had access to weekly supervision by a licensed psychologist during the intervention, four hours in total, plus an extra two hours if needed. Half (48%) of the coaches reported that they had little prior experience of using acceptance and commitment programs, whereas 52% reported that they regularly used acceptance and commitment exercises in their studies and daily life. The coaches conducted the preliminary and post-interviews (with the iACTface group), introduced the participants to the intervention program and procedure, and remained in weekly contact with them (both the iACTface and iACT groups). Each coach was assigned three to ten participants to follow. They also participated in the pre- and post-measurements (for all three groups). The Group Protocols and Measurement Procedures The iACTface group The participants in the iACTface group received a web- and mobile-delivered intervention program called Youth COMPASS. Before the program, this group also had a face- to-face meeting with their individually assigned coach, which comprised a structured interview and discussion (45 min) about the adolescents’current life situation. The interview questions were shortened and adapted for the adolescents from a psychosocial interview template (Strosahl et al. 2012). These adolescents were also given oral instructions and an instructions sheet with credentials for the Youth COMPASS, which explained how to work in the web program and how and when to complete the weekly assignments. In a second face-to-face meeting, which followed the five-week intervention, the adolescents in this group were interviewed by the coach about their intervention experiences. During the five-week intervention, these adolescents had a short weekly contact with their coach via instant text messages (using the WhatsApp mobile application. See https://www.whatsapp.com/). The iACT group The participants in the iACT group received the same web- and mobile-delivered intervention program as those in the iACTface group. However, the iACT group participants had no individual face-to-face meetings with their coach. Instead, they received credentials and a brief introduction to the Youth COMPASS program, instructions and an instructions sheet for the web program, and a timetable for weekly assignments. The iACT group participants also had short weekly contact with their coach via instant text messages (SMS). The control group The control group was not provided with intervention resources or feedback. They (as well as the iACTface and iACT groups) only received normal support from the school, such as the possibility to liaise with school health professionals regarding psychological and other well-being- related issues or to get personal support for learning difficulties. The Intervention Program The Youth COMPASS is a five-week online program aimed at enhancing adolescents’psychological flexibility by guiding them in exploring their interests, thoughts, emotions and sensations, setting goals, and changing behaviors according to their goals: learning acceptance, defusion, and Table 1 Participants in the different groups and analyses Initial phase characteristics iACTface group (n=81) iACT group (n=80) Control group (n=82) Participants in the intention-to-treat analyses N (%) Female 44 (54.3) 37 (46.3) 38 (46.3) Male 37 (45.7) 43 (53.7) 44 (53.7) Poor academic skills N (%) Normally developing academic skills 41 (50.6) 40 (50.0) 40 (48.8) Poor academic skills 40 (49.4) 40 (50.0) 42 (51.2) Reason for poor academic skills N (%) Unknown reason for poor academic skills 18 (22.2) 16 (20.0) 18 (22.0) Reading problems 9 (11.1) 11 (13.8) 11 (13.4) Math problems 7 (8.6) 7 (8.8) 8 (9.8) Both reading and math problems 6 (7.4) 6 (7.5) 5 (6.1) Participants in the per-protocol analyses N (% from the intention-to-treat protocol) 64 (79.0) 58 (72.5) 82 (100) Included/excluded cases (N) in the per-protocol analyses Female 39/5 33/4 38/0 Male 25/12 27/17 4/0 Two different analytical protocols (intention-to-treat and per-protocol) were used, as recommended for intervention studies (Ranganathan et al. 2016) 292 Journal of Youth and Adolescence (2019) 48:287–305 mindfulness skills (week 1), broadening these skills into self-compassion (weeks 2–3), and learning adaptation skills for use in the adolescents’personal and social life (weeks 4–5). The program was inspired by the acceptance and commitment intervention models for youth (e.g., Ciarrochiet al. 2012; Hayes and Chiarrochi 2015) and especially by the experiences gained by university students from the COMPASS program (Räsänen et al. 2016), although the youth version was designed to be more playful, and the exercises were shorter and modified into digital form. The program consisted of short texts, pictures, video clips, comic strips, and audio-based exercises and could be accessed via PC, laptop, tablet, or mobile phone. Each of the five modules was divided into an introduction and three different levels, including a set of short exercises based on the particular process of psychological flexibility. The participants had to complete at least two exercises in each level to be able to advance in the program. The first exercise was mandatory, whereas the other exercises could be chosen from a selection of four to seven short exercises. Thus, to complete a week of exercises, the participants needed to pass at least six different exercises, although it was possible to complete all the exercises if they so desired. Most of the exercises were offered in both written and audio-recorded form. Around half of the exercises demanded more mental orientation (such as the mindfulness exercises) and selfreflection, while the other half required behavioral responses (such as doing an exercise, writing a response, or seeking answers). Altogether, the intervention program included more than 90 exercises, which were usually no longer than five to 10 min. The coaches were able to follow the progression of their personally guided adolescents and to provide motivational feedback via SMS once weekly using semi-structured questions. Before giving feedback, the coach was instructed to check via the program’s platform whether the adolescent had completed the weekly exercises. The weekly feedback via SMS comprised three semi-structured questions (shown in Table 3): How are you doing? Please rate your mood during the last week on a scale from 4–10 (4 = very bad, 10 =very good). The scale from 4 to 10 is commonly used in Finnish schools for grading schoolwork; therefore, it was familiar for all of the participants. A question related to each step, such as What is important to you? What could you do today or tomorrow to add joy and energy to your life? Do it! (This is an example from feedback questions for Module 1). When the adolescent replied via SMS, the coach sent her/him an encouraging message with a closing phrase: Looking forward to hearing from you next week! If the adolescent did not reply, the coach was instructed to send an SMS as a reminder, wait one day, and re-send the SMS message with the feedback questions. If no Table 2 Sample characteristics in the three groups Baseline characteristics All (n=243) iACTface group (n=81) iACT group (n=80) Control group n=82) Age M (SD) 15.27 (0.39) 15.25 (0.30) 15.27 (0.33) 15.29 (0.50) Gender Female 124 (51%) 44 (54.3%) 37 (46.3%) 38 (46.3%) Male 119 (49%) 37 (45.7%) 43 (53.8%) 44 (53.7%) Mother tongue Finnish 230 (94.7%) 77 (95.1%) 74 (92.5%) 79 (96.3%) Other than Finnish 8 (3.3%) 3 (3.7%) 3 (3.8%) 2 (2.4%) Bilingual (Finnish + some other language) 4 (1.6%) 1 (1.2%) 2 (2.5%) 1 (1.2%) Living with Mother and father 167 (68.7%) 52 (64.2%) 59 (73.8%) 56 (68.3%) Only with mother or father 20 (8.2%) 12 (14.8%) 4 (4.1%) 4 (4.9%) Alternately with mother and father 38 (15.6%) 11 (13.6%) 12 (15.0%) 15 (18.3%) Othersa14 (5.7%) 4 (4.9%) 3 (3.8%) 7 (8.5%) Parental Education (primary caregiver) A/B/C (%)b33/25/42 (%) 34/20/46 (%) 41/22/37 (%) missing casesc21 9 14 aLiving with mother and stepfather, father and stepmother, foster care or approved home. Parental education level: bA=vocational upper secondary education or lower, B =vocational college degree, C =Bachelor’s degree or higher. Information of education level was missingcin some cases Journal of Youth and Adolescence (2019) 48:287–305 293 Table 3 The structure and content of the youth COMPASS intervention and related coaching activities Core modules Aims Levels (L1 to L3) and themes Coach’s QuestionsaExamples of exercises and activities 0. Introduction Brief orientation to the online intervention Getting started: Introduction (text & video)/Be Your Own Life’s Hero (3 videos) A brief introduction to the Youth COMPASS program (worksheet) 1. Direction For Life ACT processes: Finding personal interests and goals Recognition of activities that provide energy, well-being, and joy. Examining possible obstacles in achieving them. Taking actions and concrete steps toward personally valued goals. Introduction L1: What is important in my life? L2: What do I want to achieve in my life? L3: What are the barriers to achieving goals? What is important to you? What could you do today or tomorrow to add joy and energy in your life? Do it! Text, video, and comic strip L1: Strength Cards L2: Goal Cards L3: BOLDb 2. Me And My Mind ACT-process: Promotingawareness of self and acceptance and cognitive defusion skills Exploring automatic thoughts and feelings. Acceptance of thoughts, feelings, and memories as they are. Developing awareness of the self-as- context. Cognitive defusion, i.e., taking an observer’s perspective toward one’s own thoughts and feelings. Introduction L1: Me and my mind L2: Watching one’s own mind L3: Practicing defusion skills You can choose how to relate to your own thoughts. Try to act differently from what your mind suggests. See what happens. What could you do that provided you energy this week? Video: Is The Mind So Clever? Video Thoughts About Myself L1: Thoughts As L2: Soap Bubbles L3: Thoughts In My Pocket 3. “Stalking Myself” ACT-process: Being in the present and practicing acceptance Taking a new stance on my thoughts and feelings. Learning how to be mindful here and now and applying these skills to everyday life. Introduction L1: Observing one’s senses L2: Being in this moment (NOW) L3: Applying skills to everyday life Tell us what kinds of skills—related to being in the moment—you have used in your everyday life. What kinds of consequences did you observe while using them? Video and comic strip: Feelings in My Body L1: Before You Snap Out L2: Mindfulness L3: Through Music 4. Me and Myself ACT-process: Recognizing the self as a context and providing self-compassion Perceptions of oneself and learning to take a different perspective to one’s thoughts and emotions and applying these skills to one’s own life Introduction L1: Who am I and how do I act L2: Changing one’s perspective L3: Getting rid of stories of oneself Kindness toward self is important. How can you treat yourself kindly (in a similar manner as your friend who has difficulties)? Text, video, and comic strip L1:You in Social Media L2: Sky and Weather L3: Me and My Blunders 5. Me and Other People ACT-process: Applying important actions to social life and being compassionate toward others Promoting good relationships with friends and other people and applying ACT-based skills to social life. Introduction L1: Being a friend to yourself and others L2: Living in the world L3: Facing challenging life situations What kinds of good things have you done for other people in the past week, or what could you do next week? Text, video, and comic strip L1: Critique Hurts L2: Change the World L3: Preparing For Stressful Events Coach’s Questionsa: All weekly contacts were started using two basic questions: (1) How are you doing? (2) Please rate your mood over the last week on a scale from 4–10. These were followed by the third question presented above. bBOLD is an exercise by Ciarrochi et al. (2012) 294 Journal of Youth and Adolescence (2019) 48:287–305 meaningfulness of the findings, one must consider the sensitivity of the measures, the severity of the symptoms (i.e., the amount of stress and academic buoyancy), and their prevalence in the explored sample. This issue can be estimated using statistical tools if the effect size and prevalence of disorders in a specific sample are known (see the illustrative presentation by Coe 2002; see also Griner et al. 1981). Following this, the effect sizes found in the present study (although being in line with those in general samples; see Swain et al. 2015) were weaker than typically observed among clinical samples, with specific difficulties in stress management and academic buoyancy (e.g. Livheim et al. 2015; Livheim 2004). Yet, the found effect sizes were also good in light of the statistical view presented above (i.e. Coe 2002 and Griner et al. 1981). However, in the future, clinical study samples should also be used to obtain insights into the clinical significance of the effects of the program. Another limitation relates to the lower adherence rates among male participants compared to those among females. An analysis of the non-completers (25% of adolescents randomized to the intervention groups) showed that they were mostly male, and they reported having lower levels of initial stress and higher buoyancy than those who completed the program (see also APA 2014; Wiklund et al. 2012). However, in some earlier studies, boys have also been observed to use avoidance and distraction methods as a means for coping with stress (APA 2014; see also the Teen Help website). Thus, the high number of male participants who did not experience stress or commit to the program may reveal an avoidance and distraction strategy rather than actual stress levels and interest in the program. Nevertheless, it seems that male participants do not as easily commit to this kind of intervention as females. Motivation strategies, especially by male participants, ought to be carefully considered in future intervention studies. The focus of the current study was on 15- to 16-year-old ninthgrade adolescents who were attending their last year of lower secondary school. In future studies, it would be important to explore whether this kind of brief intervention is also useful among younger and older samples of youth, as well as in other educational and cultural contexts. Afinal limitation is that only stress, school-related stress, and academic buoyancy were examined as outcomes of the intervention. Because acceptance and commitment practices are thought to have broad effects on well-being (e.g., Hayes et al. 2012), the reported measures give a slightly narrow view of the possible effects of the Youth COMPASS intervention. It is also notable that the two used measures of stress may tap different aspects of it and thereby influence the results. The overall stress measure is likely to assess more strongly the degree of current stress symptoms, whereas the school stress scale is likely to assess the longterm experiences of school-related stress (i.e., the extent to which school-related demands exceed students’resources) that resemble students’experienced level of school-related exhaustion (Salmela-Aro et al. 2009). These differences might have partly affected the measures’sensitivity to detect short-term changes in the stress experiences (cf. relatively stronger intervention effects were observed overall stress than in relation to school-related stress). In addition, the role of the coach–participant interaction in motivation or the impact of the number and different types of intervention exercises on the outcomes could not be explored in the current article, but these will be important to clarify in future studies. More studies are needed to confirm the findings of the current study. Practical Implications The findings of the current study are promising and propose that this kind of intervention could be used as a preventive and early tool for alleviating stress and promoting coping skills among adolescents. The study also suggests that it would be useful to investigate further the potential of webbased acceptance and commitment interventions among adolescents. This study opens possibilities to expand the repertoire of currently available school-based programs. It would be interesting to fit the program into regular school curriculum practices and to apply it to all pupils in a class. Web and mobile technology makes this kind of intervention feasible, easy to implement, and cost effective, and it may reduce the risk of stigma by normalizing interventions provided for mental health (Ciarrochi et al. 2012; Hayes and Ciarrochi 2015). In addition, the program could generate new ideas and understanding for teachers and other professionals in their work with adolescents. An intervention study that applies Youth COMPASS to a clinical sample would be interesting given the findings of the current study. It is likely that the program would work even better with adolescents who experience psychological distress and who may be more highly motivated to participate in and take advantage of the program. However, when using clinical samples, it would be important to provide participants with the possibility of personal contact with a healthcare professional. In addition, small weekly group meetings could provide different therapeutic elements, such as peer support for same-age adolescents with similar experiences (Livheim 2004; Livheim et al. 2015). This could further help adolescents become more aware and accepting of their inner experiences and to achieve their personal life goals and interests, thereby promoting the targets of acceptance and commitment therapy (Ciarrochi et al. 2012; Hayes and Chiarrochi 2015). Journal of Youth and Adolescence (2019) 48:287–305 301 Modern technology can also increase the possibilities of applying programs to diverse settings, such as schools and in a variety of leisure activities. These kinds of interventions do not necessarily demand specialized skills, and they can be used by different kinds of professionals working with adolescents. In addition, the programs can also increase adults’understanding of psychological skills that are important not only for adolescents, but also for all human beings. However, it is also important to observe that the theoretical views that are mostly “hidden”in the program can be misunderstood, which may lead to misuse and a devaluing of the program if users do not have proper knowledge of the theoretical background behind the program. In addition, modifications are needed for future study designs and protocols. Conclusions Acceptance and commitment interventions have been used thus far among adult samples with clinical disorders and symptoms, but little is known about how the interventions work as preventive and early tools in alleviating diverse psychological symptoms (here, stress) and promoting wellbeing and health (here, academic buoyancy) among nonclinical samples of adolescents. The current study presented a novel intervention, Youth COMPASS, aimed at promoting adolescents’mental health by combining mobile and web technology, along with the acceptance and commitment model. The program includes multiple, brief exercises that have features resembling more games than traditional intervention exercises. Of interest was also the examination of whether academic skills affect the intervention results. The results demonstrated a statistically significant reduction in symptoms of overall stress and an increase in academic buoyancy. In addition, the gains in the interventions were larger among those whose stress levels at the initial stage of the study were highest. Moreover, poor academic skills did not influence the intervention outcomes. The results suggest that acceptance and commitment models and programs are also feasible for early intervention among young people. Furthermore, the results indicate that mobile technology may be of assistance in youth interventions and may provide elements—such as enhanced self-knowledge and more autonomy over one’s actions—that promote the targeted goals of acceptance and commitment therapy. This, in turn, opens new directions for enhancing the health and wellbeing of adolescents, which can be applied in diverse settings, including schools. More detailed studies and analyses of the contents of the program and their connection to the intervention gains are needed. Special attention is needed to build the motivational aspects of the exercises before and during the program. Acknowledgements Open access funding provided by University of Jyväskylä (JYU). Authors’Contributions AP conceived of the study, planned the intervention program, drafted the manuscript and analyzed the data; RL and PL planned the intervention program; JM analyzed the data using MPLUS; KE and TA planned the study design and randomization, and RH helped with data interpretation. NK helped with data interpretation, led the main study including implementation of the data collection and interventions, and was responsible for participant recruitment. All authors critically revised the manuscript for important content. All authors read and approved the final manuscript. Funding This study was funded by the Finnish Cultural Foundation, the Central Finland Regional Fund, and the Multidiciplinary Research on Learning and Teaching profiling action financed by the Academy of Finland (No. 292466 for 2015–2019) and personal funding to RH from the Academy of Finland No 2016-2019. Data Sharing and Declaration The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request. Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval This study was conducted in compliance with APA ethical standards. It was approved by the Ethics Committee of the University of Jyväskylä, and has been registered at ClinicalTrials.gov. Informed Consent Informed consent was obtained from all the participants of the study. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://crea tivecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Appendix 1 Table 6 Table 6 Mean scores and standard deviations at pre- and postmeasurement in intervention groups Scale Group Pre-M (SD) Post-M (SD) Overall Stress iACT 2.98 (1.33) 2.73 (1.18) iACTface 2.91 (1.53) 2.87 (1.30) School Stress iACT 2.93 (0.80) 2.88 (0.76) iACTface 2.88 (0.85) 2.85 (0.77) Academic Buoyancy iACT 3.53 (0.84) 3.75 (0.79) iACTface 3.54 (0.86) 3.70 (0.79) In the iACT group (n=80), iACTface (n=81) 302 Journal of Youth and Adolescence (2019) 48:287–305 References Andersson, G., & Titov, N. (2014). Advantages and limitations of internet-based interventions for common mental disorders. World Psychiatry,13(1), 4–11. https://doi.org/10.1002/wps.20083. APA (American Psychological Association). (2014). Stress in America. Retrieved from http://www.apa.org/news/press/releases/ 2014/02/teen-stress.aspx. Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. 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How do eHealth programs for adolescents with depression work? A realist review of persuasive system design components in internet-based psychological therapies. Journal of Medical Internet Research,19(8), e266 https://doi.org/10.2196/jmir.7573. Anne Puolakanaho is a senior researcher at the University of Jyväskylä, Department of Psychology. She is interested in mindfulness, acceptance and commitment therapy, child and youth development, and modern technology applications in human science. Raimo Lappalainen is a professor at the University of Jyväskylä. He is interested in acceptance and commitment therapy, web- and mobilebased interventions, and brief psychological interventions. Päivi Lappalainen is a researcher at the University of Jyväskylä. She is interested in acceptance and commitment therapy, web- and mobilebased interventions and brief psychological interventions among people of different age groups. Joona Muotka is a university teacher at the University of Jyväskylä. He is interested in quantitative statistics in human research. Riikka Hirvonen is a researcher at the University of Jyväskylä. Her research interests include students’well-being, motivation, and learning-related emotions and behavior. Kenneth Eklund is an adjunct professor at the University of Jyväskylä. He is interested in reading development and reading disability: development, stability, and identification. Timo Ahonen is an emeritus professor at the University of Jyväskylä. He is interested in learning and learning disabilities, clinical child neuropsychology, and developmental psychology. Noona Kiuru is a professor at the University of Jyväskylä. She is interested in youth development, well-being, and social relationships; large-scale interventions; and longitudinal studies. Journal of Youth and Adolescence (2019) 48:287–305 305