The Child ’ s Voice in Determining Program Acceptability for a School-Based Mindfulness Intervention

School-based mindfulness interventions have been shown to be effective in reducing mental health symptoms. However, comparatively little research has investigated the acceptability of these programs from the perspective of the children. Program acceptability underpins engagement, and more engaging programs are also more efficacious (Cowan & Sheridan, 2003; Mautone et al., 2009) yet there is little literature which has considered the acceptability of school-based mindfulness programs. To address this gap, semi-structured interviews were conducted with upper primary aged children (N = 30) who had participated in a six week mindfulness program in four Australian primary schools. Thematic analysis of interviews revealed children found the program to be acceptable. Children reported that they enjoyed doing the mindfulness program, would recommend it to others, and learned about relaxing as well as felt relaxed while doing the program. Children also highlighted the use of culturally appropriate teaching materials and possible stigmatisation as threats to the acceptability of the program. The results of the study support the acceptability of mindfulness programs in school settings, grounded in the unique perspective of the child.


Introduction
Research into the effectiveness of using mindfulness in school settings is growing, and initial studies show promise for improving children's wellbeing (Kuyken et al. 2013).However, evaluating programs requires more than simply considering the effect on outcomes such as anxiety reduction; a program that is not enjoyable, engaging, and acceptable to participants is unlikely to be as effective as it could otherwise be (Mertens 2015).The paucity of acceptability research regarding school-based mindfulness programs represents a significant gap in the literature (Villarreal et al. 2015).The current study seeks to understand the experience and the acceptability of participating in a school-based mindfulness group for anxiety reduction, from the perspective of the children involved, and in the children's own voices.
Anxiety issues ranging from separation to social anxiety are increasingly being identified in children at primary health care and school-based support services (Pahl et al. 2012;Sawyer et al. 2000).Anxiety issues in childhood can often manifest in school refusal, a serious problem when it becomes chronic, as it not only impacts children's learning but can reinforce avoidance as a coping strategy (Dube and Orpinas 2009;Richards and Hadwin 2011).The need to address anxiety in childhood is important so that schools can support children's education and also their long-term mental health.Utilising early intervention techniques is something both recommended by government and recognized as valuable within the educational and therapeutic communities (Tully 2007;Greenberg and Harris 2012).
The use of mindfulness techniques has seen success in treating anxiety both within the adult population as well as in childhood (Mace 2007;Harnett and Dawe 2012).Mindfulness encompasses a variety of techniques with the central premise on bringing attention to the present moment without judgement (Bishop et al. 2004).There have been more studies in recent times which have investigated the use of mindfulness based interventions for children and many have been conducted in a school-based setting (Joyce et al. 2010;Kuyken et al. 2013).School-based mental health promotion aims to support children's understanding of health matters and also serves to educate the wider community as well (NHMRC 1996).The use of mindfulness as a treatment for childhood anxiety has been well established and the implementation of school-based early intervention programs is a recommended method of promoting mental health and wellbeing in children.

Program Evaluation and Acceptability
In developing school-based intervention programs, it is essential to evaluate the acceptability of the program, in addition to the effectiveness of the implementation (Mertens 2015).Many commentators in the field of school-based interventions have identified a greater need for evidence regarding early intervention and promotion programs to ensure the quality of programs being implemented (Lyon et al. 2014).Qualitative data regarding an intervention offers researchers a means of gaining an in-depth understanding of what participants think about the logistics of the program as well as whether they actually like doing it (Forman et al. 2009).The use of qualitative data to inform program modification and assess acceptability is indispensable for any program evaluation (Fabiano et al. 2014).
Despite the potential value of acceptability data and more specifically, qualitative acceptability data, there is a paucity of such research (Villarreal et al. 2015).Acceptability data has been positively associated with efficacy data in intervention research (Eckert and Hintze 2000).This is consistent with earlier research on engagement in treatment whereby those involved in a treatment will only benefit from it if they attend and engage in it (Wolf 1978).Kazdin (1980) defined treatment acceptability as the extent to which those non-professionals involved in a treatment judge it to be fair, reasonable, appropriate and non-intrusive.Research has demonstrated links between treatment acceptability, ratings, and the efficacy of the treatment to the extent that the acceptability of treatment can actually contribute to its efficacy (Cowan and Sheridan 2003;Mautone et al. 2009).This finding highlights the inherent value of acceptability data to an overall program evaluation.

Acceptability of Mindfulness Interventions with Children
The use of school-based mindfulness early intervention programs has gained significant momentum in recent years, supported largely through the wider evidence for mindfulness theory and its application (Greenberg and Harris 2012;Harnett and Dawe 2012).Some qualitative studies that investigate the depth behind mindfulness interventions and their acceptability to participants alongside quantitative information are emerging.A study of note is that of an Australian school based mindfulness meditation program for children in upper-primary (Joyce et al. 2010).Quantitative results demonstrated a reduction in symptom severity related to psychological distress and qualitative data was also collected from the teachers involved in the research.The themes that emerged indicated teachers considered students to be enthusiastic about the lessons and overall felt they benefited from the strategies used.
Another school-based mindfulness program was investigated by Kuyken et al. (2013).This intervention was presented to young people as a skill-set for dealing with everyday stressors and experiences.Students involved in the program showed significant stress and depression symptom reduction compared to controls at follow-up.In addition to this, students were asked to complete feedback questionnaires regarding the acceptability of the program, if they enjoyed it, and whether they utilized the skills learned in daily life.Feedback from the students demonstrated they were quite positive about the program and enjoyed it.A majority also reported using some of the strategies in daily life after completing the program.The researchers indicate the study provides solid evidence for the feasibility of their mindfulness intervention in both symptom reduction as well as acceptability to students.
More recent research into the acceptability of school-based mindfulness interventions for children has been conducted with a particular focus on children who may have psychosocial issues.This research shows that children provided valuable qualitative information about mindfulness and its impact in their lives via various means of enquiry such as interview and written responses (Costello and Lawler 2014;Viafora et al. 2015).Mindfulness is often seen by children as helpful with respect to being calm, focussing and gaining control of emotions.In some cases, even when quantitative data do not produce statistically significant results, qualitative data can be used to inform about real-world significance as well as to provide feedback related to improvements or changes to the program (Coholic 2011;Viafora et al. 2015).
The aim of the current study was to explore the acceptability of a mindfulness-based group program for children.Given the paucity of qualitative research into acceptability for children in school-based mindfulness programs (Villarreal et al. 2015), a thematic analysis of childrens' experiences was expected to offer significant insight and add to existing knowledge in the area.

Program Intervention
The six week mindfulness intervention program (TRIPLE R: Robust, Resilient, Ready to Go) was developed by a not-for-profit non-government organisation and the delivery was supported by provisionally registered psychologists enrolled in Master of Psychology (Counselling) and Master of Psychology (Educational and Developmental) courses.At least one school teacher was present at each session.Ethics approval was granted for the study by the Monash University Human Research Ethics Committee (project no: CF14/2118-2014001119), which was conducted in accordance with the Declaration of Helsinki.
The TRIPLE R program uses one hour weekly sessions to deliver a combination of mindful activities, mindfulness practice, and psycho-education centred on a particular theme, such as the body, feelings, mind, and relationships.Previous evaluations of the TRIPLE R program with upper primary aged children found evidence for increased mindfulness skills (Dove and Costello 2017) and improved emotional regulation (Bannirchelvam et al. 2017).For more information about the program see Dove and Costello (2017).

Participants
Four government primary schools in Melbourne, Australia elected to be involved in the program, which was supported by local government funding.Selection for the program varied across the schools.One school chose to deliver the program to an entire class, while three schools chose to screen children for inclusion according to a range of criteria: identified by parents or teachers as having difficulties with anxious or depressive symptoms manifested through school nonattendance, limited peer friendships, social isolation/withdrawal, non-participation in class activities, and/or repeated attendance at sick bay.Participation was voluntary, consent was sought from both parents and children, and counselling for ongoing support after the completion of the program was made available if desired.Participants were free to withdraw from the program at any time.
The program was delivered to 96 children enrolled in grade 5 and grade 6 (typically aged nine to 11 years).From the four schools, a total of 30 children (17 males, 13 females) were randomly selected to participate in the current study, with the only inclusion requirement being that participants had attended all sessions of the program.The mean age of the sample was 10.5 years old and ranged from 9 years of age to 12 years of age.To ensure participant anonymity, no further demographic details were recorded.Participants were included in the current study only if they indicated that they were willing (in addition to parental consent).Participants were also informed that their names would not be used by the interviewer during recording.

Procedures
In the week following the completion of the final TRIPLE R program session, qualitative data was collected from participants via individual private interview at the school.The semi-structured interview included open-ended questions in order to allow children to elaborate as much as they would like (Creswell 2008).Interviews were conducted and audio recorded by the first author, who also assisted in delivering the program at two of the schools, but was not the lead interventionist.Each interview began with a brief ice-breaking conversation in order to build rapport.It was established first and foremost that the participant sufficiently recalled participating in the TRIPLE R program.The questions used were based on those used in similar acceptability studies investigating school-based mindfulness interventions (Costello and Lawler 2014;Viafora et al. 2015).The interviews were also designed to be sufficiently brief so that participants would not be overly burdened by the process (Hutchfield and Coren 2011).Prompts and encouragement such as: 'can you tell me a little more' or 'what was that like?' were given to participants in order for them to expand on any answers which may have been ambiguous or too brief.
The following questions were included in the semi-structured interview: 1.
Can you tell me a bit about the TRIPLE R project? 2.
Can you tell me about something in TRIPLE R that you really liked? 3.
Can you tell me about something you really didn't like? 4.
Can you tell me a bit about Mindfulness? 5.
How have you been feeling in the past few weeks/days since we finished TRIPLE R? 6.
Do you have any final thoughts or comments about TRIPLE R? 7.
What might you say to other children who are about to do TRIPLE R?

Qualitative Data Analysis and Validation
Interviews were transcribed verbatim by the interviewer following the recording.The study used an exploratory approach whereby there were no expectations from the data other than learning how the TRIPLE R program was perceived by participants.Thematic analysis was applied to review and code the data (Braun and Clarke 2006;Guest et al. 2011).Transcripts were read several times to highlight the emerging themes and notes were made by certain responses which appeared on a regular basis across participants (Guest et al. 2011).These common responses were coded and then integrated together to identify broader themes by using a spreadsheet (Braun and Clarke 2006).Those themes deemed most prevalent across participants were further clarified through the continued filtering of related themes into a broader over-arching theme, each time being related back to the original transcript data.Analysis sought information indicating the acceptability of the program, indications for improvements to the content or implementation, and what participants knew about mindfulness.
To complement the thorough review of transcripts and themes, further data validation took place via external consultation.The credibility of the data and themes was sought through peer debriefing with a psychologist who was not involved in the current study.Audits for dependability and confirmability of the data were obtained in a similar way whereby the external psychologist checked the transcripts and notes of the researcher to ensure all themes were present within the data itself and that appropriate extraction of themes had taken place (Braun and Clarke 2006).

A Thematic Perspective of Program Acceptability
Thematic analysis of the qualitative data revealed several strong themes which came from the interviews, and these were further refined under three higher order themes.Participants believed that TRIPLE R was a good program; that they found that it helped with relaxing; and that there were some things they did not like.Further interpretation of each higher order theme is expanded on below.All children remembered doing the program and were able to report sufficiently well on something about the program.Verbatim quotes from participants have been included to illustrate aspects of the themes.

The Mindfulness Program "Is Good"
Participants generally reported the activities in the program to be fun and interesting.More than half spoke of how they really enjoyed the various games or group activities in which they learnt about mindfulness, and how to understand thoughts, feelings and behaviours.Participants were divided on the meditations however, with around half saying they liked it and the other half saying they didn't.However, for the most part, participants liked doing the activities even if they did not always like the audio meditations.
"I liked when we did the person and we wrote about feelings and drew inside it of what the feeling's like."(Participant 4) "I liked ah, when we listened to the CD in resting position and it told us what to do like breathing and stuff like that."(Participant 7) Related to this was the overwhelming response from participants that there was nothing they disliked about the program.A majority of participants could not think of anything they would change or disliked about the program.Indeed, if there were any suggestions of things they disliked or would like to change (other than the meditations), these were often external to the program itself such as the timing or scheduling of it or the behaviour of other children in the program.
"Um there was nothing I really didn't like . . .um no I don't think there was anything I didn't like."(Participant 25) "Well, there was nothing I really didn't like, everything was good but like, maybe they could have like done a bit of a session outside?" (Participant 27) Another strong element of this theme was that most children indicated that they would recommend others to do the program as well.They considered the program a worthwhile experience and some even asked if they could do it again.When asked what they would say to others about doing the program, responses indicated a positive evaluation of doing the program such as it being fun, relaxing and worth the investment in time.
" . . .Don't think it's gonna be boring because that's what I thought at the start but when I got there it was actually really fun so just give things a go." (Participant 4) "Well, I think it's really good, like it does really help."(Participant 1)

The Mindfulness Program "Helps with Relaxing"
While there was no expectation that children would find the TRIPLE R program relaxing, the overwhelming number of participants on being asked about what they liked, what they knew about mindfulness or any other comments, spoke about how relaxing they perceived the program was to be, including helping them to relax between classes and generally feel calmer.
"Um, it's nice to relax in the middle of school when schools pretty hard and all you do is work pretty much."(Participant 2) "Well it calms you down and helps you relax and go on with your day." (Participant 10) Further to this, participants also reported that they found the activities helped them to know how to help themselves relax outside of the TRIPLE R program.There were various accounts from children who demonstrated how they had used relaxation or mindfulness techniques at home."Um, I thought it's a good thing to um, teach children for like when they grow up like it's good to show them at an early age.Um, and yes it can help them in the future, so like if you're getting angry at someone you can just calm yourself down."(Participant 6) "Um it helped me a bit with my confidence and how to deal with my brother, basically.So yeah it's helped."(Participant 21) Another positive finding was that the majority of participants reported feeling good and often better in the week after doing the TRIPLE R program.No participants reported feeling worse and some participants even reflected on feeling more confident and having fewer arguments after doing TRIPLE R. "I've been feeling a lot better with my thoughts, and I'm going to sleep better, before that program I couldn't go to sleep and I kept waking up in the middle of the night and so now I don't wake up in the middle of the night and if I ever do, I just go back to sleep so...And the most . . . the thing that's most impacted on me is that they said your thoughts aren't always right.And I thought they were right so that's why I was getting scared."(Participant 3) "Ah, much calmer when it comes to things that make me frustrated and if somethings making me frustrated I'll sit down and just breathe it out."(Participant 7) While the response with respect to program acceptability was positive for a variety of reasons, the most evident reason that emerged from the data was that TRIPLE R was relaxing.Many comments made about the program being relaxing were offered without probing, emerging from the core questions asked to all participants.Children were able to identify specific activities they enjoyed, grasp the concept of mindfulness and describe something about it.There was very little about the program itself which participants would change.

Criticisms of the Mindfulness Program
The only element on which there were divided opinions was the audio meditations which were liked and disliked in almost equal proportions.When it came to those who disliked the audio meditations, children were able to provide valuable feedback as to what about it they did not enjoy.For some it was the voice on the recording, for others it was a challenge to stay still.
"I didn't like the meditation thing because I couldn't keep still, cos, yeah . . .I can't really do meditation without holding my head like that, so I had to keep it like that so it doesn't look like I'm silly."(Participant 3) Another valuable element of feedback which was perhaps more subtle in the data related to possible stigma experienced by some participants.Three out of the four schools selected children to participate based on behavioural reports from school staff and teachers, while the fourth school delivered the program to all children in the one year level.A small number of selected participants were apprehensive about why they were asked to do the program.For example, two selected participants indicated that they would advise others that "they should give it a go despite what others might say about you".Stigma which may result from program selection procedures is a barrier to program acceptability.

Discussion
The purpose of the current study was to understand the experience and the acceptability of participating in a school-based mindfulness intervention.This was investigated using qualitative interviewing after the completion of the program, and the use of thematic analysis.Three higher order themes emerged, providing evidence that the program "was good", "was relaxing", and "criticisms", demonstrating the acceptability of the program from the perspective of the child participants.
The results directly support the concept of treatment acceptability as identified by Wolf (1978) such that a treatment is acceptable if it is deemed socially valid by those involved, essentially whether the treatment is liked, felt useful or believed to be important.Indeed, the second higher order theme identified by the participants would tend to suggest that, given the relaxation strategies introduced by the TRIPLE R program, it could be very effective in addressing anxiety for these children.There is emerging evidence that the program improves mindfulness skills (Dove and Costello 2017) and improves emotion regulation (Bannirchelvam et al. 2017).The combination of emerging evidence for program efficacy and acceptability has wider implications for mindfulness interventions in school settings.
It was significant to note that children could identify how they learnt how to relax, and also that they found the program itself to be relaxing.The results of the current study are supported by similar results found in the school-based mindfulness intervention studies of Viafora et al. (2015) as well as Felver et al. (2014).In both of these qualitative studies, participants were able to demonstrate the reality of learning mindfulness techniques in their lives such as helping to stay calm and less stressed, to be able to pay more attention in class and also to feel better.Together these results are indicative of the acceptability of mindfulness based interventions from the perspective of the child.
The participants in the current study reported that they "felt better" after doing the program.This is consistent with the findings of Coholic (2011), who used an arts-based mindfulness intervention for children and assessed acceptability via interview.Coholic found that children simply felt happier after doing the program.The majority of children in the current study reported a similar experience of generally feeling better and more relaxed after doing the TRIPLE R program.Positive affect towards an intervention program is a strong indicator of program acceptability (Villarreal et al. 2015).
Not all aspects of the program were deemed acceptable by the participants.There were divided reactions to the audio meditations.Some children really liked the time spent in meditations, describing it as relaxing.Other children found the meditations boring and difficult to engage with.The audio meditations were also delivered by a speaker with an American accent with some children reporting that the voice was "funny" or "weird".Alternative types of meditation such as moving meditation or mindful eating, could be considered rather than audio meditations, or local accent recordings used if program acceptability is to be improved.
The subtle suggestion of stigmatisation relating to program selection was concerning.An extensive review of child mental health literacy research identified stigma as a key area of challenge for youth mental health (Riebschleger et al. 2017).It is noteworthy that no participants from the school that elected to use the program with a whole class indicated any stigma or concern about being selected.This has implications for school settings where the choice of a selective or universal intervention program (Fazel et al. 2014) may inadvertently increase stigma and threaten the acceptability of the program for children.Komulainen (2007) identified the difficulty of working with children qualitatively such that their honesty can be skewed by the socialized context of the interview.The participants in the current study could also have been influenced by familiarity with the interviewer in the context of program delivery rather than outside it.To mitigate these risks, participants were encouraged to be open about aspects that were not enjoyable, and the interviewer engaged in peer debriefing and audits for dependability and confirmability with an external psychologist (Mertens 2015).While the threats to data quality need to be acknowledged, it is equally important to note the advantages.Qualitative data regarding program acceptability from the children themselves is arguably more relevant than from other sources, and using a known interviewer minimises the threat of relational or rapport difficulties.

Conclusions
The current study sought to explore acceptability for mindfulness-based programs for children delivered in a school setting.Given the links between program acceptability, engagement, and efficacy (Cowan and Sheridan 2003;Mautone et al. 2009), establishing the acceptability of school-based mindfulness programs from the perspective of the child adds substantially to the literature.The results of the current study provide useful and important evidence for the value of obtaining acceptability information from children involved in the TRIPLE R mindfulness program.The participants were able to validly report on elements of the program that were acceptable, as well as elements that were less than ideal.Listening to the voice of the child about threats to acceptability was particularly poignant, highlighting the importance of utilising culturally appropriate materials and minimising potential stigma in program selection.The current study provides evidence for the acceptability of the TRIPLE R program and more broadly for the acceptability of school-based mindfulness programs, as well as cautions regarding threats to acceptability.