‘Now Whenever I Get Anxious,I Know What to Do’ : Children’s Experiences of Attending CBT-Informed Group Therapy in a Child & Adolescent Mental Health Service (CAMHS)

Abstract

The importance of involving healthcare consumers in service user experience has yet to be consistently embraced by Child and Adolescent Mental Health Services (CAMHS), despite recognition from the UN’s Convention of the Rights of the Child, which emphasises the value of including children in clinical research. The Secret Agent Society (SAS) is an intensive, CBT-informed intervention for children, which aims to support emotion regulation and social problem-solving skills. SAS has a substantial international research base; however, little is known regarding the personal experiences of children who have completed the programme. This descriptive qualitative study aimed to explore children’s experiences of attending SAS groups facilitated by Senior Speech and Language Therapists (SLT) in CAMHS in Ireland. Data was collected using semi-structured, one-to-one interviews, with 47 children aged 8–12 years (mean age 10:11). Children’s diagnoses included ADHD, anxiety disorder and/or autism. Interviews were transcribed and analysed qualitatively using content analysis. Themes highlight the value children placed on mastering new skills and the hope that this new learning offered them for the future. A fun intervention, supported by a strong therapeutic alliance and a favourable emotional climate, were of importance to them. Completing home practice tasks was not. Findings give a voice to neurodivergent children attending SLT-led group therapy in CAMHS, beyond what previous research has established using quantitative methods. The depth of experiences described emphasise the importance of optimising the therapeutic environment and have implications for future neuro-affirmative group interventions.

Keywords

children’s experiences CAMHS CBT qualitative research

Introduction

The importance of involving healthcare consumers in service user experience is gaining increased momentum in mental health research today. In 2019, Ireland’s Mental Health Reform Committee concluded that giving voice to people with direct experience of using mental health services should be at the heart of mental health policy and service provision (My Voice Matters, 2019). However, the significance of evaluating consumer experience has yet to be embraced within all areas of mental health, particularly within the domain of child mental health, where there is a dearth of research (McGrath et al., 2022). This is despite recognition from the UN’s Convention of the Rights of the Child which highlights the importance of including children in clinical research and emphasises the right of children to have their voices heard (United Nations, 2014).

In the last decade there has been an unprecedented rise in referrals to Child and Adolescent Mental Health Services (CAMHS) in Ireland and in the UK, with referral rates to CAMHS in England more than doubling in the last five years (Newlove-Delgado et al., 2021). Mental health problems for children are more prevalent than ever before, yet specialist CAMHS services are underfunded, under-resourced and in a state of overwhelming demand (Green, 2023). Hence it is essential that scarce therapeutic resources are used optimally and evaluated to determine whether interventions offered result in children’s acceptability and satisfaction (Leahy & McNicholas, 2021). Qualitative evaluation is particularly pertinent for CAMHS where this type of research is needed to understand how to better engage children (McNicholas et al., 2016), how to prevent drop out (Mc Grath et al., 2022) and how to aid recovery (Coyne et al., 2015). Additionally, understanding children’s experiences of mental health services, and how these relate to their needs and priorities, is essential to achieving child centred care (Day et al., 2011).

Recent emerging literature indicates that there has been a shift towards investigating children’s experiences of attending community-based mental health interventions (e.g. in primary care clinics, schools, hospitals, academic institutions). Researchers have explored children’s experiences of attending psychotherapy (Carlberg et al., 2009; Pernebo & Almqvist, 2016), bereavement support (Metel & Barnes, 2011), equine-assisted therapy (Dunlop & Tsantefski, 2018), cognitive behaviour therapy (CBT) (Lilja et al., 2021; Makund & Jena, 2022; Panditaratne et al., 2022) and music therapy (Parr Klyve & Rolvsjord, 2023). In contrast, there is a paucity of research investigating the experiences of children with moderate-severe mental health disorders, who typically fall within the remit of CAMHS. The limited research that exists has explored participant views of CAMHS provision in general (e.g. Buston, 2002; Coyne et al., 2015; Damodaran & Sherlock, 2013; Donnellan et al., 2013) or satisfaction with overall care related to ADHD specifically (e.g. McGrath et al., 2022). These studies focused primarily on the viewpoint of adolescents, rather than primary school children. Despite their young age, primary school children have proven ability to give clinically valuable accounts of their experiences and expectations of therapy (Carlberg et al., 2009), yet research into these experiences is limited.

The Secret Agent Society (SAS) is an evidence-based, multimedia therapy programme for primary school children that targets emotion regulation and social communication support needs (Beaumont & Sofronoff, 2008). Based on the principles of CBT, SAS teaches children how to identify and cope with their emotions and how to understand and manage social interaction (https://www.secretagentsociety.com/). It combines various therapeutic modalities including weekly clinic sessions for children, parent and teacher training, computer game access and home/school activities. Effectiveness has been investigated in mainstream schools (Beaumont et al., 2015), on an individual basis (Tan et al., 2015; Thomson et al., 2015), remotely via telehealth (Beaumont et al., 2021; Lee et al., 2024; Sofronoff et al., 2015), in specialist autism classes (Einfeld et al., 2018), in hospital and university clinics (Beaumont et al., 2019; Temkin et al., 2022) and more recently with children with mental health disorders attending Speech and Language Therapy (SLT) in CAMHS (MacEvilly et al., 2024). Most prior SAS research has examined effectiveness from a quantitative point of view only (e.g. through analysis of pre and post numerical outcomes following completion of standardised questionnaires/rating scales). Yet qualitative approaches have been found to provide complementary insights to quantitative research, highlighting depth and details that quantitative methods may fail to capture (Jackson et al., 2024).

To the authors’ knowledge only three studies have investigated detailed experiential aspects of the programme. Costley et al. (2020) explored parent, teacher and facilitator engagement in school-based SAS. Lee et al. (2022) investigated parent and facilitator experiences of participating in an online format of SAS. Children’s experiences were not explored in either of these studies. Mootz et al. (2022) sought feedback from children, their parents and teachers regarding their experiences of SAS. However, this was a feasibility study focusing on telehealth and the sample size was small (5 children). To date, no study has explored the perspectives of children who have completed face to face SAS groups. Knowledge of these perspectives could reveal aspects of the intervention that are most engaging and meaningful for children, potentially leading to better therapeutic outcomes and informing wider service development.

Aim

This study provides the first qualitative evaluation of SAS in CAMHS by exploring children’s experiences of participating in the programme. The guiding question was, ‘how do primary school children with moderate-severe mental health disorders experience SAS?’

Methods

Ethical Permissions

St John of God Research Ethics Committee granted ethical approval for the study (ID675). Informed consent was obtained appropriately.

Design

A descriptive, qualitative design was employed to obtain detailed insight into children’s experiences.

Study Setting and Participant Recruitment

This paper reports on the qualitative exploration of children’s experiences. It is part of a larger, mixed methods quantitative evaluation of SAS, facilitated by Senior SLTs, in an Irish outpatient CAMHS, from children’s, parents’ and teachers’ perspectives (MacEvilly et al., 2024).

Three separate SAS programmes were delivered concurrently across three geographically distinct CAMHS clinics in the East of Ireland, encompassing both urban and rural areas. Each clinic was comprised of a multi-disciplinary team led by a Consultant Child and Adolescent Psychiatrist. Purposive sampling was used. Three Consultant Psychiatrists working in each of the clinics acted as gatekeepers in the recruitment process. They provided families who met inclusion/exclusion criteria with a parent information brochure and a child specific leaflet.

Participants in this qualitative part of the study were children who completed the SAS programme and attended the final group session. Children’s parents and their teachers were also interviewed on their experiences of attending SAS. These findings are undergoing analysis and will be reported in future publications.

Inclusion Criteria

(1) Children with a moderate-severe mental health disorder (that which significantly impacts daily functioning across a number of settings) as confirmed by their Consultant Psychiatrist. Children were also required to have clinically significant emotion regulation and social communication support needs.

(2) Children aged between eight and twelve years.

(3) Children attending mainstream school, with average or above average intellectual ability, as measured by school reports or cognitive assessment.

Exclusion Criteria

(1) Children whose language skills fell significantly below the average range, to ensure they could fully understand programme content. This is in line with the programme developer’s recommendation that children’s language skills should be at least equivalent to that of an eight-year-old (Beaumont et al., 2019).

(2) Children with significantly challenging behaviour who may not have been amenable to group participation.

(3) Children unable to communicate fluently through English.

Families who wished to partake in the study contacted their Consultant Psychiatrist. Following this, further information was given and an interval of seven days provided prior to seeking consent. Gatekeepers then sent consent and assent forms for parents and children, along with a stamped addressed envelope. When forms were returned, researchers contacted parents directly.

The study comprised forty-seven children (males n = 28, females n = 19). Children’s mean age was ten years eleven months. Demographic information is outlined in Table 1. Children’s primary diagnoses comprised ADHD, Anxiety Disorder, autism or a combination. Secondary diagnoses included Sensory Processing Disorder, Dyslexia and Dyspraxia. Children were all Caucasian, born in Ireland and spoke English as their primary language. One child was bilingual. Participants were from a range of socioeconomic classes, from both urban and rural communities.

Table 1.

Children’s Demographic Information

Characteristic	Variable	N	(%)
Gender	Male	28	60
	Female	19	40
Age	8–12 years	47	100
Mean age	10; 11
Primary diagnosis	Autism	11	23
	ADHD	10	21
	Anxiety Disorder	10	21
	Autism + ADHD	8	17
	Autism + Anxiety Disorder	7	15
	ADHD + Anxiety Disorder	1	2
Secondary diagnosis	Sensory Processing Disorder	4	9
	Dyslexia	4	9
	Dyspraxia	5	11
On medication	Yes	22	47
On medication	No	25	53
Type of medication	Methylphenidate	13	28
	Atomoxetine	1	1
	Melatonin	4	9
	Selective Serotonin Reuptake Inhibitors	4	9
Attended SAS only	Yes	45	96
Attended SAS only	No*	2	4
*Other intervention	Art Psychotherapy	1	2
*Other intervention	Sensory Strategies Parent Workshop	1	2

At the time of recruitment, twenty-two of the children (47%) were in receipt of medication relating to their mental health disorder. Five were in receipt of more than one prescribed medication. One child commenced medication (methylphenidate) following the seventh session. Two participants received additional therapeutic support over the intervention period (Art Psychotherapy and a Sensory Strategies Parent Workshop). All forty-seven children completed the programme.

Programme Content

SAS comprises four parent information sessions and one teacher training session, the content of which is reported elsewhere (e.g. MacEvilly et al., 2024). The programme should be delivered by trained, certified SAS facilitators who are typically allied health and education professionals. In this study, nine x 90-minute sessions were delivered weekly to groups of five-six children by two clinical researchers, who were also Senior SLTs working in CAMHS and trained SAS facilitators. Table 2 outlines programme content. Sessions progressed from teaching skills such as recognising and labelling emotions, to more complex skills such as using relaxation strategies. Between sessions children completed ‘Home Missions’ to promote generalisation of skills. They also played the SAS computer game at home with a parent. Tracker cards allowed monitoring of and subsequent rewarding for children’s practice of skills at home and at school.

Table 2.

Content of SAS Programme

Session	Content	Activity examples
1	Detecting emotions in others	Detection of the Expression game
1	Detecting emotions in others	Voice Transmission Device game
2	Detecting anger + anxiety in ourselves	Identification of body clues
	Identifying strength of emotions + situations that cause them	Creation of personalised Emotionometers
	O2 regulator	Creation of personalised Emotionometers
3	Relaxation gadgets	Challenging enemy thoughts game
3	Relaxation gadgets	Attach relaxation stickers to Emotionometers
4	Envirobody Scan	Creation of Friendship Formula potion
4	Preferred friendship ingredients	Completion of personalised Friendometer
5	DECODER problem-solving formula	DECODER practice
6	Preferred conversation topics	Secret Agent Fact Files
6	Hanging out with others	Play Code steps
7	Coping with mistakes	Damage Control Steps
7	Detecting the difference between accidents, jokes + nasty deeds	SAS Board Game
8	Types of bullying	Bully Disguises
8	Why people bully	Bullying Exposed
9	Preventing + managing bullying	Bullyguard Body Armour activity
	Coping with uncertainty	Confusion Code steps
	Coping with uncertainty	Future planning + party

Outcome Measure

Children completed nine group sessions of SAS before taking part in the qualitative evaluation. Although they attended a group intervention, children’s experiences were considered to potentially include sensitive or personal information. Therefore, it was decided to interview children individually, rather than together.

Prior to the commencement of the research study, the Programme Satisfaction Questionnaire (PSQ), developed and recommended for use by SAS developers (Beaumont & Sofronoff, 2008), was piloted by the clinical researchers with twenty-one children following completion of their SAS groups in CAMHS. No changes were made to the questionnaire for the current study. The PSQ (Table 3) addresses themes relating specifically to children’s experiences of attending SAS, thus reflecting the overall objective of the study.

Table 3.

Programme Satisfaction Questionnaire (PSQ)

What did you like about SAS?

What helpful things did you learn?

What did you not like about SAS?

What did you find unhelpful?

How would you make SAS better?

What else would you like to say about SAS?

Data Collection

Fifty-one children completed the SAS group intervention. Forty-seven children took part in the interviews which were held during the children’s final group session across each of the three CAMHS clinics. Four children could not attend on their final day due to illness. Interviews were conducted by the researcher who knew the child best from his/her involvement in the group intervention and with whom the child already had a rapport. Children took it in turns to leave the group and accompany the researcher to her therapy room for the interview. They returned to the group straight after. Each child and their parent had attended a pre group consultation session with this researcher in the same room prior to the commencement of the intervention, so children were familiar with the interview setting.

Interviews began with a clear explanation of their purpose and a statement to each child that there were no right or wrong answers. It was emphasised that the children were the experts and that the researcher wanted to learn from them. Researchers endeavoured to be warm and encouraging towards the children, prompting discussion and further explanation by using clarifying and exploratory questions (Day et al., 2011). Open-ended questions were asked to avoid biasing the direction of children’s answers. Prompts were used to expand on responses given, where necessary (e.g. ‘can you tell me more about that?’, ‘can you explain what you mean?’). An effort was made to maximise children’s enjoyment of the interview, achieved through their preferred choice of seating and provision of fidget toys, as well as specific praise for taking part.

Interviews lasted 10-15 minutes, depending on each child’s level of engagement and ability. By the end of the interview, no further responses had been given and data saturation had been reached. Children’s responses were transcribed verbatim by hand for later typing, electronic storage and analysis. During the transcription process, all children were assigned a pseudonym to maintain anonymity. In order to allow the children to converse naturally, without hyperawareness of their opinions being captured for research purposes, it was decided that audio recording would not be used. Although transcription led to a slight delay following each response, researchers have suggested that this approach is more appropriate and yields better quality data in certain circumstances (Rutakumwa et al., 2019).

Data Analysis

All data was subjected to a process of inductive analysis, a form of thematic analysis that aims to code data in the absence of a pre-existing coding framework. Inductive analysis is based on Burnard’s (1991) model of thematic content analysis, adapted from Glaser and Strauss’s (1967) grounded theory approach and other models of content analysis. It aims to develop descriptive themes grounded in participants’ responses, representing, as closely as possible, the actual experience and insights of those interviewed.

Following data collection, analysis was undertaken initially by repeated readings of the data by the principal investigator, followed by line-by-line review of the transcribed interviews, in order to identify significant ‘units of meaning’ (Markham & Dean, 2006). These units of meaning were then manually given descriptive codes. Conceptual saturation was reached when no new codes emerged from the data. All coded data was then summarised into categories of descriptive themes. A second researcher reviewed the codes and themes to ensure participant views were not lost and to validate those identified. Consensus on themes was reached by repeated discussion between this researcher and the principal investigator. Agreed themes were then grouped into thematic networks, giving structure and coherence to participants’ accounts (Attride-Stirling, 2001). Networks are formed by the clustering of contributory codes into Basic Themes that are then grouped to form more abstract Organising Themes, which in turn, are grouped to form super-ordinate Global Themes.

Researchers were aware of previous studies examining children’s experiences of group therapy, including bereavement support (Metel & Barnes, 2011) and equine-assisted therapy (Dunlop & Tsantefski, 2018), as previously mentioned. However, conscious attempts were made to bracket expectations and not to let possible preconceptions about these children’s experiences bias subsequent findings (Elliott et al., 1999). In order to achieve transparency within the analysis, data was grounded in examples. Accounts that departed from the dominant theme were retained and highlighted to demonstrate the full range of children’s views, as suggested by Braun and Clarke (2006). Each theme is presented with supporting anonymised extracts from participants’ transcripts.

Results

Following analysis of basic and organising themes, two Global Themes emerged from the data: ‘Intrapersonal Factors’ and ‘Transactional Factors’ (Table 4). Both themes have implications for service delivery in CAMHS, with subthemes highlighting the diversity and commonalities of children’s experiences, beyond what previous studies have established using quantitative methods.

Table 4.

Global Themes and Organising Themes

Global themes	Organising themes
1. Intrapersonal factors	1.1 Mastering new skills in emotion regulation
	1.2 Mastering new skills in social problem-solving
	1.3 Secondary benefits
2. Transactional factors	2.1 Unique features of the SAS programme
	2.2 Interpersonal relationships
	2.3 Emotional climate

Global Theme 1: Intrapersonal Factors

Intrapersonal factors are those intrinsic to the child and their personal experiences of/feelings about SAS. Three subthemes highlight these factors: mastering new skills in emotion regulation, mastering new skills in social problem-solving and secondary benefits of attending SAS, each of which will be discussed in turn.

Organising Theme 1: Mastering New Skills in Emotion Regulation

Over half of the children (N = 25, 53%) reported an increased capacity for recognising and regulating their emotions following completion of the programme and described this as helpful. The sense of mastery achieved in using the self-regulation strategies taught was central to their reflections, with positive outcomes described in children’s everyday lives:

‘I learnt that it isn’t totally impossible to calm down’ (Y8, 9-year-old boy)

‘It helps in quite a lot of situations, like if you’ve a test you’ve a lot of gadgets to calm down’ (X1, 11-year-old boy)

‘I learnt new strategies to get less anxious….it has helped me a lot with worrying and anger, because I use my strategies a lot now’ (X5, 10-year-old girl)

Children also stated that having a variety of strategies to use during times of emotional distress was key, as this afforded them a range of options to choose from when dealing with high levels of physiological arousal:

‘If one strategy doesn’t work, you have “back-ups” other than throwing yourself on the floor’ (Y12, 10-year-old boy)

‘I learnt how to cope with getting angry, I used to go to my room in a huff but now I have things to do like fidget toys’ (Y9, 10-year-old girl)

‘I learnt that there are loads of things I can do to stay calm, like play with my dog’ (X11, 11-year-old boy)

Children reported that slow, mindful breathing was the most helpful emotion regulation strategy learnt (e.g. ‘when I used my O2 regulator the first time I was calmed down in about 5 minutes’ X12), followed by physical exercise (e.g. ‘the Fire Engine really helps me calm down’ X17) and challenging enemy thoughts (e.g. ‘I learnt that whenever someone says you’re not good at something I can just use the Helpful Thought Missile’ Z8). Some children also reported that the skills would be beneficial for them in the future, contributing to a sense of increased confidence and hope:

‘Now whenever I get anxious, I know what to do’ (Z8, 10-year-old boy)

‘It helps you to create a better life for yourself knowing these things’ (Y2, 11-year-old boy)

Organising Theme 2: Mastering New Skills in Social Problem-Solving

Another frequently reported beneficial outcome, mentioned by over a third of the children (N = 18, 38%) was learning social problem-solving strategies. Children spoke about how SAS helped them to understand and cope with social situations better, leading to meaningful change. This had a knock-on effect in terms of supporting their friendships and conversations, beyond the remit of the clinic and into everyday life;

‘I learnt how to interact with other kids without panicking’ (Z2, 11-year-old girl)

‘I learnt how to keep calm, brave and how to keep friends, like if one of them was messing with you, you wouldn’t lash out at them and accuse them of bullying you when they weren’t’ (Z10, 11-year-old boy)

‘It made my school existence more friendly, calm and fun’ (Y11, 9-year-old boy)

Several children reported an increased understanding of others’ feelings (e.g. ‘I’ve learnt that everyone is equal and how other people’s feelings are just as equal as yours’ X12) and a realisation that they are not the only ones who make mistakes (e.g. ‘It showed that it wasn’t just to review your mistake, it showed you other people’s mistakes too’ Y12). Increased social assertiveness was described as children commented on the value of learning strategies to manage bullying (e.g. ‘I learnt how to deal with bullies, how to say no’ X12; ‘it can teach you new ways to deal with bullies’ Y2).

For six of the children (12%), learning about social problem-solving did not prove beneficial, as they either knew the skills already (e.g. ‘I didn’t find the conversation code helpful, as I already knew it’ X3; ‘some of the steps in the codes were blatantly obvious to me but they were helpful to others’ Z6) or they did not feel that the skills were relevant to their lives at the time (e.g. ‘the bully thing wasn’t helpful because I’m not really getting bullied’ Z3; ‘I didn’t like that some modules didn’t apply to me’ Y1).

Organising Theme 3: Secondary Benefits

The final subtheme in this section relates to the secondary benefits of attending SAS, which may have increased children’s willingness to attend the groups and incentivised their compliance with learning and practicing new skills.

The most popular secondary benefit reported was the enjoyment children experienced. The word ‘fun’ became a prominent emerging theme with eleven of the children (23%) specifically referencing how much fun they had during the activities played. It is likely that the pleasure and happiness children experienced contributed to group cohesion and rapport building, as well as increasing their motivation to co-operate with more serious session topics such as managing emotional distress or coping with bullying.

Many children also emphasised the importance of the timing of the sessions, with nearly a fifth (N = 9, 19%) highlighting the benefits of missing school or non-preferred classes in order to attend (e.g. ‘I liked missing school’ X3; ‘It helps getting out of school’ X7; ‘I get to miss maths doing fun stuff’ Y3). However, of note, the same number of children (N = 9, 19%) expressed disappointment at missing enjoyable school activities (e.g. ‘I didn’t like missing the fun things that we do in school on Thursdays’ Z4; ‘sometimes we’d be doing an exciting subject in school and I didn’t want to leave’ X8). One eleven-year-old girl described a reluctance to tell her friends why she had to leave school early, perhaps reflecting the stigma attached to attending a mental health service:

‘I didn’t like how kids just asked me where are you going? One boy tried to blackmail my friend into telling him…’ (X17)

A quarter of the children (N = 12, 25%) commented on the advantages of the token reinforcement system, which rewarded the children for being kind to each other and trying their best (e.g. ‘I liked that we got rewards for doing all the work’ X9; ‘I liked getting the prizes, that was fun’ X14). Having chocolate biscuits at break time was also mentioned as a positive for the children. Several of the older female children in particular reported increased confidence as a direct result of attending SAS, highlighting the real-world impact of the intervention that extended beyond improvements in direct skill mastery:

‘I learnt that it doesn’t really matter what people think about you’ (Z4, 11-year-old girl)

‘I feel a lot better about myself and the things I’m good at’ (Z11, 12-year-old girl)

‘I learnt that we had Bionic Powers that we didn’t know about’ (X9, 9-year-old girl)

Global Theme 2: Transactional Factors

Transactional factors are the interactions between the child and the experiences associated with the therapeutic environment. Three subthemes highlight these factors: Unique Features of the SAS Programme, Interpersonal Relationships and the Emotional Climate, each of which will be discussed in turn.

Organising Theme 1: Unique Features of the SAS Programme

When asked what they liked best about the intervention, nearly a quarter of the children (N = 11, 23%) emphasised the importance of the child friendly resources given to them to keep or played as part of the groups (e.g. collector code cards and wallet, invisible ink pen, friendship formula test tube, walkie talkies, board game). These tangible therapeutic materials provided children with an alternative, novel medium for skill learning and practice and were clearly valued:

‘I liked the things that came with it, the fidget thing and the wallet’ (X7, 11-year-old girl)

‘The stuff that you get is really interesting, especially the new pen’ (X15, 8-year-old girl)

‘I liked playing the board game’ (X5, 10-year-old girl)

‘I liked the computer games’ (Y1, 12-year-old boy)

One nine-year-old boy (Z16) commented on the advantage of teacher involvement (‘I like that my teacher knows about SAS’), while several children mentioned the helpfulness of the stress ball (e.g. ‘The ball yoke helped me’ X11; ‘I liked the squishy balls’ Z10). However, almost a fifth of the children (19%, N = 9) reported that the ‘Home Missions’ (daily skills practice tasks) assigned as part of the programme were not helpful and that removing the missions from the intervention altogether would improve it. Negative responses included dislike of Home Mission discussion at the start of the sessions (e.g. ‘the correcting of the home missions was so boring’ X3; ‘I didn’t like it when other people looked at my home missions’ Z3), the complexity of some of the tasks (‘sometimes the home missions were kind of hard’ X7) and the additional demand of the Home Missions on top of school homework (‘I didn’t like talking about the missions at home, I’ve too much other homework’ Z15).

Organising Theme 2: Interpersonal Relationships

Interpersonal relationships within the groups themselves emerged as a particularly dominant subtheme. Children described being interested in and liking each other, which is likely to have enhanced group cohesiveness (‘I liked the people that we done it with’ X11; ‘the people there were really nice’ X15). Children also identified the importance of meeting people that they had never met before (‘I liked meeting new people’ Z13; ‘I like that I got to meet new people’ Z14) which may have represented a powerful normalising experience, as they discovered they were not alone in their worries and emotional responses. Indeed, positive relationships with each other emerged as a crucial aspect of the intervention. 21% (N = 10) of the children referenced that they made new friends during SAS. They described this as welcome, beneficial and key to their engagement, even for the older children:

‘It helps you get out of your bubble, so you’re not stuck with old friends… it’s good for secondary school to make new friends’ (Y4, 12-year-old boy)

‘I got to make new friends. I made a new best friend in class’ (Z2, 11-year-old girl)

‘I liked that I got to make new friends’ (Z9, 9-year-old girl)

Organising Theme 3: Emotional Climate

Finally, children’s interview data suggested an important part of the programme’s value lay in their personal relationship with the therapists, facilitated by a supportive emotional climate. 17% of the children (N = 8) described a strong therapeutic alliance which enabled them to feel emotionally safe and secure in the group setting (‘when I came here, I felt safe and with my friends’ Z8; ‘I was able to talk about my feelings in a secure place’ Z6). Therapists were described as ‘really kind’ (X1), ‘nice’ (X8), ‘very friendly’ (X14) and ‘really helpful’ (Z11). Children also reported feeling accepted and understood by therapists, which allowed them to be themselves without fear of consequence (‘you guys didn’t snap at me when I got a bit rude’ X14; ‘the teachers – they didn’t get angry at us if we forgot something’ Z10). Acceptance and tolerance were important contributors to feelings of emotional safety and allowed children to open up and share personal experiences (e.g. ‘you could tell them if there was something going on in school’ X9).

Discussion

This article extends existing SAS research by exploring children’s experiences of the programme, an area of limited evaluation. Findings should be interpreted alongside the outcomes of the authors’ quantitative study (MacEvilly et al., 2024), thereby providing a mixed methods exploration of an SLT-led intervention. The inclusion of children’s perspectives is in line with current thinking in Irish and international research contexts, which encourages the provision of opportunities for children to voice their views (Department of Health, 2022). As previously mentioned, two Global Themes emerged from the data: ‘Intrapersonal Factors’ (factors intrinsic to the child and their personal experiences of/feelings about SAS) and ‘Transactional Factors’ (the interactions between the child and the experiences associated with the therapeutic environment).

When providing health care Mylod and Lee (2023:1) suggest that ‘reliably offering hope that a positive future state can be achieved should be one of the goals of the therapeutic relationships between clinician and patient’. This statement provides a useful framework within which the findings from this study can be conceptualised. Many children reported learning new social-emotional skills and described how they could use these skills by themselves to manage future adversity. Children as young as eight years were able to articulate their preferred and non-preferred skills and to reflect on the value of these from a personal perspective. This was also reported by four of the five children interviewed about their experiences of SAS in Mootz et al.’s study (2022). For all of us, mastering new skills increases feelings of competence and a belief in one’s own agency, thereby providing hope. This in turn makes it more likely that coping strategies may be used to manage stressors (Germann et al., 2015). Increased hopefulness was also reported by thirty-nine adolescents who completed a treatment programme for depression (Cunningham et al., 2021). Teenagers receiving inpatient and outpatient mental health care in Biering’s critical review Biering (2010) reported similar experiences. They welcomed new skills taught, to the extent that changes in their own behaviours were one of their most desirable intervention outcomes. Interestingly, at the time the current research was conducted, no studies were found on how children younger than thirteen years experienced mental health care.

Children in the current study were clear about how importantly they valued having fun, a finding that was the strongest secondary benefit of the intervention for them and one that is in keeping with previous qualitative research. For the eight children who attended music therapy in Parr Klyve and Rolvsjord’s study (2023:100), experiencing moments of fun proved to be an essential part of their mental health care. Authors stated that fun was, in fact, not just mere entertainment, but actually of ‘existential importance’ in the therapeutic process. Indeed, ensuring that treatment groups are engaging for children may allow therapists to more effectively facilitate change, whilst positively enhancing group interaction and motivation. On a related note, Kfrerer et al.’s scoping review (2023) into the use of humour in both child and adult therapeutic settings concluded that humour, fun and laughter foster group cohesion, contribute to a sense of belonging and equalise power dynamics between clients and clinicians.

All children in this study were neurodivergent and so their experience of the treatment programme was likely to be intricately linked with transactions occurring within the therapeutic environment. In line with neuro-affirmative practice, researchers were aware of the importance of optimising the environment, so that children’s neurodivergence could flourish, as recommended by Green (2023). Study findings corroborate this importance. Children responded positively to the small group format, which minimised noise levels and waiting times during games, whilst also allowing the opportunity for individual personalities to thrive. Groups took place in the morning to coincide with optimal medication effects and to minimise sensory fatigue, but some children reported concerns about leaving school early and disruption to preferred school activities. Similar group timing concerns are also highlighted in the literature, such as by adolescents attending treatment for depression (Cunningham et al., 2021) and have been noted as common barriers to treatment adherence (Meredith et al., 2009). Children in the current study appreciated the diverse teaching modalities of SAS (e.g. visual supports, computer game, rewards) but the home practice assignments were not perceived favourably overall. This is also evident in other paediatric CBT interventions, where children’s reduced intrinsic motivation for homework completion and dislike of practice tasks resulted in homework adherence rates between 50% and 60% (Gaynor et al., 2006; Wilansky et al., 2016).

Interaction between group members is a key aspect of SAS, facilitated through role play, group games, nonverbal activities and relaxation time during break. The opportunity to make new friends and experience positive interpersonal relationships with children with similar interests was considered central to many children’s perspectives. This desire for social connection has also been described by neurodivergent children in other studies and when achieved, can lead to powerful feelings of emotional connectedness (Tsou et al., 2024). This connectedness can be an especially welcome experience for neurodivergent children who may feel pressure to live up to social norms and mask their differences (Heasman & Gillespie, 2018). Indeed, the normalising effect of having comparable strengths and challenges as other children in a group, whether neurodivergent or not, cannot be overstated (Whitfield, 2010). The importance of positive interpersonal relationships has also been described in previous related and unrelated studies. Two of the five children attending virtual SAS in Mootz et al.’s study (2022) said they would have preferred to attend the programme in person, as there was less opportunity for interaction using the online format. Bereaved children described feeling less isolated and different following their group intervention (Metel & Barnes, 2011). Adolescents with depression found social connection between group members to be the most important part of their treatment (Cunningham et al., 2021) and autistic adults reported experiencing a sense of shared identity and belonging when meeting others like them (Milton & Syms, 2016).

Children in the current study valued the emotional climate of the groups and described how the responsivity of clinicians facilitated feelings of emotional safety, where difficulties could be explored without fear of consequence. This mirrors the emerging research on the human aspect of care in children’s clinical environments, whereby the importance of the therapeutic relationship should not be underestimated (McGrath et al., 2022). Indeed, the therapist’s ability to understand the child was found to be a facilitator for treatment engagement and change in Panditaratne et al.’s evaluation (2022) of a CBT programme for children with intellectual disabilities and was a prerequisite to being helped in Day et al.’s investigation (2011) into children’s experiences of mental health care. On a similar note, a strong therapeutic alliance was described as central to patient centred care by Kfrerer et al. (2023) and highly valued by parents of adolescents with ADHD (McGrath et al., 2022). Meza et al.’s (2023) recent review of randomised control trials investigated the treatment elements common to interventions targeting suicide/self-harm in young people. A strong therapeutic alliance and relationship with the clinician emerged as one of the core elements.

Clinical Implications

The significance of these findings is that responses were provided by children who completed a treatment programme in CAMHS, rather than their parents or CAMHS professionals. To the authors’ knowledge, this represents the first formal research opportunity for children with moderate-severe mental health disorders to share their experiences of CBT-informed group therapy led by SLTs in CAMHS. This is particularly important given that traditionally, research in child and adolescent psychiatry has overlooked the involvement of consumers with lived experience who receive interventions (Werner-Siedler & Shaw, 2019), despite growing acknowledgement that qualitative research has much to offer child and adolescent psychiatry (Kandasamy et al., 2019).

Some of the key themes to emerge highlight the value young children placed on new skill mastery and the hope that these skills offered them for the future, particularly in the domain of emotion regulation. Responses emphasised other areas of consideration that may have implications for neuro-affirmative group interventions in CAMHS. These included the contribution that the therapeutic environment makes to children’s experiences of their care, the value of fun activities and the importance of the emotional climate. In addition, the opportunity to make friends and meet new people was praised by many children, suggesting that they preferred group intervention rather than one to one therapy. Some children questioned the value of home practice tasks and others disliked missing school to attend. As a result, researchers simplified home practice tasks for subsequent groups, suggesting a talking format for homework and offered afternoon groups to minimise school disruption. These programme modifications underscore the need for a flexible approach to providing group therapy for children with moderate-severe mental health disorders.

The Irish Government has emphasised the importance of service user feedback when developing patient centred services (Government of Ireland, 2006). However, obtaining feedback from primary school children receiving mental health care in Ireland is not yet a priority. Youth opinion should be sought in all studies aiming to improve child mental health services (McGrath et al., 2022), thereby ensuring that the intended consumers of interventions are heard. It is only by understanding children’s views that tailored interventions to support the specific needs of those attending CAMHS can be developed.

Limitations

Study findings are an exploratory account of children’s experiences of attending one specialist intervention in a community CAMHS setting and so are tentative in nature. Generalisability is limited by children’s demographics (all Caucasian, born in Ireland, most monolingual) and should be determined by the reader.

Several limitations should be acknowledged when interpreting the findings, including the narrow age range (8–12 years), the absence of a comparison group and the fact that interviews were conducted by a clinical researcher who was also a programme delivery facilitator. This may have resulted in children being susceptible to responder bias, as they may have felt compelled to express more positive attitudes than would be the case if they did not know the researcher. However, the fact that children had a relationship with the researcher may have made it more comfortable for them and reduced the ‘power differential’ (Spyrou, 2011). It is acknowledged that researcher bias and/or prior experiences could have shaped analysis, although measures were taken to mitigate this (e.g. dual coding).

Future qualitative research using a randomised design with a larger sample size may yield themes generalisable to a larger proportion of children. Allowing children to draw or write answers to interview questions or to respond through the use of technology may enhance the scope of data collection and richness of responses. Analysis of how children with specific diagnoses experienced the treatment programme was outside the scope of this article but will be examined in future publications. Parent and teacher experiences of participating in SAS will also be explored. This study did not include patient and public involvement (PPI) in its design, as the concept and formal frameworks for PPI had not been established at the time the study was initiated. Future SAS studies should actively incorporate PPI to align with best practice in clinical research.

Conclusion

These exploratory findings give a voice to neurodivergent children with moderate-severe mental health disorders attending CBT-informed group therapy in CAMHS. Understanding how children experience mental health care is of utmost importance and is consistent with the growing international movement that seeks to explore children’s views. The experiences described provide a unique insight into the complexities associated with child centred intervention and have implications for future neuro-affirmative service delivery and research within SLT and beyond.

Footnotes

Acknowledgements

The researchers would like to thank the children who participated in the study and Mr Peter Gallagher (Research Department, St John of God Community Services) for his assistance.

ORCID iD

Deirdre MacEvilly

Ethical Considerations

The St. John of God Research Ethics Committee granted ethical approval for the study (ID675). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.

Consent to Participate

All study participants gave informed consent in writing.

Consent for Publication

Informed consent for publication was provided by participants in writing.

Funding

Grant funding was obtained through the St John of God Development Company to purchase SAS resources for participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Due to the nature of qualitative data and ethical considerations, the research data cannot be shared.*

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