"I can't escape my scars, even if I do get better": A qualitative exploration of how adolescents talk about their self-harm and self-harm scars during cognitive behavioural therapy for depression.

Emerging evidence indicates that perceptions of self-harm behaviours and self-harm scars may thwart recovery from depression, yet limited research has explored adolescent accounts of their self-harm and scars during therapy. This study sought to explore how adolescents describe their self-harm behaviours and scars during Cognitive Behavioural Therapy (CBT) and explore the sociocultural discourses that may influence these descriptions. The participants were six female adolescents (aged 14-17 years old) with clinical depression, who were engaging in self-harm. All participants accessed CBT as part of clinical trial evaluating three psychological treatments for major depressive disorder in Child and Adolescent Mental Health Services. Audio-taped CBT sessions were analyzed using discourse analysis. Within CBT sessions, adolescents drew upon stigma discourses in talking about their self-harm. Adolescent also described their self-harm scars as shameful and stigmatizing, and as "proof" of the legitimacy of their depression. It is important for CBT practitioners to understand the context of sociocultural discourses around self-harm behaviours and self-harm scars, which are reflected in how adolescents with depression describe these within therapy and may serve to maintain distress. The study indicates that awareness of use of language and intersecting sociocultural discourses can inform CBT practice.

We know that when teenagers are in treatment for depression, perceptions of their self-harming behaviours and self-harm scars can impact recovery. We also know that wider sociocultural beliefs around self-harm tend to be negative and stigmatizing, which might impact how teenagers perceive their self-harm and scars. This study aimed to explore how depressed adolescents talk about their self-harm behaviours and their self-harm scars during therapy for depression. The participants in this study were six female teenagers (aged 14-17 years old) with depression, who were engaging in self-harm. These teenagers participated in a type of therapy called Cognitive-Behavioural Therapy as a part of a larger study evaluating treatments for teenage depression in Child and Adolescent Mental Health Services in the UK. The therapy sessions were recorded, transcribed, and analyzed with a focus on the language used by the teenagers to describe their self-harm and scars. Within the therapy sessions, the teenagers talked about their self-harm in stigmatizing ways, which reflected prominent societal-held beliefs about self-harm. The teenagers in the study also believed that while their self-harm scars were shameful and stigmatizing, the scars also provided a sense of validation that their depression was legitimate. The findings of this study suggest that it could be helpful for therapists to consider how wider sociocultural beliefs around self-harm may impact how teenagers talk about their self-harm and scars in treatment for depression.

Lessons learned from conducting mental health intervention research in schools in the global south: Our experiences in South Africa and Kenya.

Most of the world's population of young people live in lower-and middle-income countries (LMICs; (Weine, Horvath Marques, Singh, & Pringle, 2020)), and these young people experience heightened rates of known risk factors for developing mental disorders such as poverty and exposure to trauma (Atwoli, Stein, Koenen, & McLaughlin, 2015). Access to professional psychological treatments is limited in LMICs due to structural barriers (e.g., a dearth of trained professionals) and cultural factors like stigma and beliefs about mental health and illness. Therefore, schools, which are widely attended, may be a good location for providing mental health interventions, and it is important that we develop and evaluate feasible, acceptable, effective, and scalable interventions for use in this context. Yet under 10% of clinical trials of psychotherapies (Venturo-Conerly, Eisenman, Wasil, Singla, & Weisz, 2022) have been conducted in LMICs. And there are particular challenges to conducting research in schools, as has been highlighted in the UK context by Moore et al. (2022). Building on that commentary, our aim herein is to share our learnings from conducting psychotherapy research in schools in Kenya and South Africa.

Four Steps To My Future (4STMF): acceptability, feasibility and exploratory outcomes of a universal school-based mental health and well-being programme, delivered to young adolescents in South Africa.

OBJECTIVE: Mental health disorders affect many children in South Africa, where vulnerability is high, and treatment is limited. We sought to determine the feasibility and acceptability of a universally delivered classroom-based programme for the promotion of mental health in young adolescents. METHOD: We pilot tested an 8 session, cognitive-behavioural therapy-based programme, 4 Steps To My Future (4STMF) in two schools. Participants were grade 5 learners (n = 222; Meanage = 10.62 (Standard deviation = 0.69)). 4STMF was delivered in class time by trained psychology postgraduates. Feasibility (rates of parental opt-out, child assent, assessment completion at baseline and follow-up, programme completion, session attendance and programme fidelity), acceptability (teacher feedback and focus groups with learners), as well as demographic data and data on a battery of a psychological measures were collected at baseline, postintervention and at one-month follow-up. RESULTS: Most eligible learners at both schools agreed to participate (85% - school 1; 91% - school 2) with more than 80% completing postintervention measures. Learner session attendance and programme fidelity were high. Teachers rated facilitators highly on confidence, preparedness, enthusiasm and classroom management and observed children to be enjoying the programme. Focus group data suggest that learners liked the programme, could recall the content and had shared some of the content with their family. An exploratory analysis of outcomes showed significant pre-post differences on self-esteem at school 1 and on emotion regulation at school 1 and school 2, maintained at follow-up. CONCLUSIONS: This pilot study has shown that 4STMF can acceptably and feasibly be delivered, at classroom level, as a universal school-based prevention programme to young adolescent learners in South African primary schools. The programme could fit in with school context, could be delivered by nonspecialists, showed significant improvements on self-esteem and emotion regulation and was liked by the learners.

In Context: Lessons About Adolescent Unipolar Depression From the Improving Mood With Psychoanalytic and Cognitive Therapies Trial.

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive-behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. CLINICAL TRIAL REGISTRATION INFORMATION: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com; ISRCTN83033550.

Sharing information about mental health services: To reach adolescents where they are, we need to market early help provision on social media.

There is a large and widening gap between the need for mental health help and timely access to services for adolescents. To enable adolescents to access evidence-based help when they first begin to struggle, we need widespread public health messaging which promotes prompt problem recognition and encourages and facilitates help-seeking. Current messaging approaches are often to share information on websites, but adolescents do not tend to look at these. Adolescents have an almost ubiquitous presence on social media, including using these platforms to seek information and support. As mental health professionals and researchers, we need to capitalise on their presence in this space and share messages about early help and support in ways that are engaging, relevant, credible, and perceived to be trustworthy by adolescents. To do this, we need to learn from our interdisciplinary colleagues with social marketing expertise, and from co-designing messages and messaging strategies with adolescents themselves. We illustrate the unique value that each of these partners can bring to improve how information about early help for mental health is shared.

Illness Perceptions, Fear of Cancer Recurrence, and Mental Health in Teenage and Young Adult Cancer Survivors.

Background: The Common-Sense Model of illness self-regulation underpins illness-specific cognitions (including both illness perceptions and a fear of cancer recurrence; FCR). There is evidence in adults of associations between FCR, illness perceptions, and mental health in adult cancer survivors. However, there is limited empirical research examining these constructs within the developmentally distinct population of adolescent and young adult (AYA) survivors of cancer. The current study aimed to bridge that gap to inform potentially modifiable treatment targets in this population. Method: A cross-sectional, correlational design was used to examine the associations between illness perceptions, FCR, and mental health. A web-based survey was completed by a convenience sample of AYA survivors. Regression and mediation analyses were performed. Results: Overall, more negative illness perceptions were associated with more severe FCR and greater depressive and anxiety symptomatology. Higher FCR was predictive of worse overall mental health. More negative overall illness perceptions predicted the relationship between FCR-depression, mediating 24.1% of the variance. Contrastingly, overall illness perceptions did not predict or mediate the relationship between FCR-anxiety. However, the specific illness perceptions regarding timeline, personal control, and emotional representation, were predictive of the FCR-anxiety relationship. Discussion: Illness perceptions and FCR were predictive of mental health outcomes. Identifying and therapeutically targeting negative illness perceptions in those young adults who have survived adolescent cancer could therefore be a means of reducing anxiety and depressive symptomatology. Limitations and future directions are discussed.

Frontline professionals' use of and attitudes towards technology to support interventions for adolescents with depression symptoms: A mixed methods survey.

METHOD: Cross-sectional survey of a convenience sample of professionals in the UK (N = 115, including low intensity practitioners, GPs, education staff, school nurses). The survey included rating scales and free text boxes. Quantitative data were analysed descriptively, and we used reflexive thematic analysis for the qualitative data. RESULTS: Frontline professionals rate their technological competence as good and have favourable attitudes towards using technology to support adolescents with depression symptoms. They rated online resources as most useful with mild-moderate symptoms, compared to severe symptoms (t(110) = 14.54, p < .001, Cohen's d = 1.49). Technology was viewed as important to bridge the needs-access gap and professionals were interested in learning about online SSIs due to usefulness (r = .32, p < .001). CONCLUSION: Technology, such as SSIs, are of interest to mental health professionals and may be useful for supporting adolescents with depression. Future research should explore the use of SSIs for treating adolescent depression.

A Brief Description of How Teachers Experience An Infographic Loneliness Toolkit About Supporting Adolescents to Overcome Loneliness.

Loneliness is a common experience amongst adolescents. As adolescents spend much of their time in school, it is important that school staff can support adolescent students experiencing loneliness. The current study aimed to explore teachers' experiences of a 1-page loneliness toolkit regarding adolescent loneliness. An online survey to collect ratings and descriptions of experiences was distributed to secondary school teachers. Findings showed that both self-rated knowledge and experience of students experiencing loneliness were positively correlated with how useful teachers found the loneliness toolkit. Three themes were developed about how useful teachers found the toolkit; clarity, brings attention to loneliness, and communication. Two themes were developed about how the user experience of the toolkit could be improved; education, and interactive student support. Future research should investigate more effective methodologies aimed at supporting adolescents experiencing loneliness to aid teachers in supporting their students.

How do adolescents experience a newly developed Online Single Session Sleep Intervention? A Think-Aloud Study.

BACKGROUND: Sleep problems are common in adolescents and have detrimental impacts on physical and mental health and daily functioning. Evidence-based treatment like cognitive behaviour therapy for insomnia (CBT-I) is often hard to access, and adolescents may not engage in and adhere to longer, clinician-delivered interventions. Brief, self-guided, and accessible sleep interventions are needed. OBJECTIVE: To explore the user experience of a prototype online self-help single session sleep intervention developed for adolescents. METHODS: Eleven participants aged 17-19 years (8 females, 3 males) took part in online retrospective think-aloud interviews. Participants first completed the prototype intervention independently and were then shown the intervention page by page and asked to verbalise their thoughts and experiences. Transcripts were analyzed thematically. RESULTS: Participants found the intervention helpful. Four themes were generated - 'Educative: Learning, but more fun', 'Effortless: Quicker and Easier', 'Personalization: Power of Choice', and 'Positivity: Just Good Vibes'. The theme 'Educative: Learning, but more fun' encompassed two sub-themes 'Opportunity to Learn' and 'Aesthetics and Learning'. These themes reflected participants' views that the intervention was educative, personalised, solution-oriented and easy to use, but could incorporate more graphics and visuals to aid in learning and could be made more effortless and positive through modifications to its design. CONCLUSIONS: Findings convey the importance of ensuring educative well-designed content, personalization, a positive tone, and ease of use while designing interventions targeting adolescents's sleep and mental health. They also indicate areas for further developing the intervention.

Investigating the factors associated with meaningful improvement on the SF-36-PFS and exploring the appropriateness of this measure for young people with ME/CFS accessing an NHS specialist service: a prospective cohort study.

OBJECTIVES: Paediatric myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is relatively common and disabling, but little is known about the factors associated with outcome. We aimed to describe the number and characteristics of young people reaching the 10-point minimal clinically important difference (MCID) of SF-36-Physical Function Subscale (SF-36-PFS) and to investigate factors associated with reaching the MCID. DESIGN: Prospective observational cohort study. SETTING: A specialist UK National Health Service ME/CFS service, Southwest England; recruitment between March 2014 and August 2015. PARTICIPANTS: 193 eligible patients with ME/CFS aged 8-17 years reported baseline data. 124 (65%) and 121 (63%) with outcome data at 6 and 12 months, respectively. OUTCOME MEASURES: SF-36-PFS (primary outcome). Chalder Fatigue Questionnaire, school attendance, visual analogue pain scale, Hospital Anxiety and Depression Scale, Spence Young People Anxiety Scale, Clinical Global Impression scale and EQ-5D-Y (secondary). RESULTS: At 6 months 48/120 (40%) had reached the MCID for SF-36-PFS. This had increased to 63/117 (54%) at 12 months. On the Clinical Global Impressions, 77% and 79% reported feeling either a little better, much better or very much better. Those with worse SF-36-PFS at baseline assessment were more likely to achieve the MCID for SF-36-PFS at 6 months (odds ratio 0.97, 95% confidence interval 0.96 to 0.99, p value 0.003), but there was weaker evidence of effect at 12 months (OR 0.98, 95% CI 0.97 to 1.00, p value 0.038). No other factors at baseline were associated with the odds of reaching the MCID at 6 months. However, at 12 months, there was strong evidence of an effect of pain on MCID (OR 0.97, 95% CI 0.95 to 0.99, p value 0.001) and SF-36-PFS on MCID (OR 0.96, 95% CI 0.94 to 0.98, p value 0.001). CONCLUSIONS: 40% and 54% of young people reached the MCID at 6 and 12 months, respectively. No factors at assessment (other than SF-36-PFS at 6 months, and pain and SF-36-PFS at 12 months) are associated with MCID of SF-36-PFS at either 6 or 12 months. Further work is needed to explore the most appropriate outcome measure for capturing clinical meaningful improvement for young people with ME/CFS.

Technology Matters: Online, self-help single session interventions could expand current provision, improving early access to help for young people with depression symptoms, including minority groups.

Current mental health service provision for young people was primarily designed based on an assumption of repeat attendance to enable access to interventions. This applies to in-person therapy and, in recent years, digitally provided apps and programmes. Yet, discontinuation after only one or two attendances or uses is a common problem. However, there is a different model, which is intentionally designing provision without assuming repeat attendance, that is, single session interventions. Evidence from the United States, where a suite of digital, self-help single session interventions, accessible anonymously, have been designed, indicates that these are helpful to young people with reductions in depression symptoms at up to 9 months later. These interventions also have had better reach into currently underserved populations (e.g. LGBTQ+ and ethnic minority adolescents). Therefore, these may be a potentially helpful way to expand existing provision at scale, enabling all young people to access evidence-based help quickly.

"I'm always going to be tired": a qualitative exploration of adolescents' experiences of fatigue in depression.

Adolescent depression is a prevalent and disabling condition, but current psychological treatments are only moderately effective. One way to enhance outcomes is to further our understanding of adolescent depression and improve our capacity to target the most frequently reported and problematic symptoms. A common but often neglected symptom of depression is fatigue, which is associated with considerable impairment and has the potential to interfere with adolescents' engagement in psychological therapies. Despite this, the experience of fatigue in adolescent depression and how we target it in treatment is currently poorly understood. Therefore, we aimed to explore adolescents' experiences and understandings of fatigue in depression, recruiting from clinical and community settings. Semi-structured interviews were conducted with 19 UK-based adolescents aged 14-18 years old with elevated symptoms of depression. Using reflexive thematic analysis, three themes were generated. Fatigue is a complex concept explored adolescents' understanding of fatigue as a dynamic, multifaceted symptom which had mental and physical components. Trapped in a cycle of fatigue considered the complex and reciprocal relationship between fatigue and other depressive symptoms, and the subsequent impact of limited energy on engagement with everyday activities. Finally, stigma as a barrier to help-seeking highlighted how adolescents were reluctant to seek help due to experienced stigma and the perception that fatigue was not a serious enough symptom. Findings from this study suggest that fatigue should be viewed as a psychological as well as somatic symptom of depression, with implications regarding the identification and treatment of fatigue in depression in routine clinical practice.

Psychological therapists' perceptions of adolescent depression and its treatment: A mixed methods online survey.

BACKGROUND: Challenges to implementating interventions for adolescent depression exist. Exploring the perceptions of key stakeholders in the treatment of adolescent depression is essential for improving implementation . This study aimed to explore psychological therapists' perceptions of, and experiences treating, adolescent depression to identify future avenues for exploration. METHOD: Data were collected opportunistically via a survey integrated within an e-learning package about adolescent depression. RESULTS: Participants believed that adolescent depression was characterised by adolescents' lack of understanding, isolation, and a lack of hope and knowledge. Participants overcame engagement barriers by building trust. Following the e-learning, participants expressed increased understanding of the risk factors associated with adolescent depression and of assessment using different measures. Several key areas for future research to explore were identified and discussed, including (1) whether clinicians of different modalities or at different career stages have difference perceptions, (2) how to meaningfully engage adolescents in treatment and (3) how to train clinicians on different modalities so patients have a choice over their treatment. CONCLUSION: This study demonstrates the value of knowledge gained from understanding psychological therapists' perceptions and illustrates how this can contribute to the improved treatment of adolescent depression.

Self-evaluation and depression in adolescents with a chronic illness: A systematic review.

OBJECTIVE: To conduct a systematic review to establish what is known about the relationship between depression and self-evaluation in adolescents with a chronic illness. METHODS: A systematic search was conducted using MEDLINE, EMBASE, PsycINFO, Web of Science, The Cochrane Library, and hand-searching. We sought to identify primary research that examined both the cross-sectional and longitudinal associations between depression and self-evaluation in adolescents with chronic illness. The search resulted in 8941 retrieved articles that were screened against an inclusion criteria. A total of 4 papers were included in the review. The MMAT used to assess study methodological quality. RESULTS: A narrative synthesis was conducted, and a summary figure was included. These 4 studies included 236 adolescents aged 9-18 years with depression and either Type 1 Diabetes (T1D), chronic pain, headaches, or Inflammatory Bowel Disease (IBD). The limited existing evidence indicated that that depression was associated with negative self-evaluation in adolescents in some but not all chronic illnesses investigated to date. We also found some evidence that psychological intervention can help to improve self-evaluation, specifically in adolescents with T1D. CONCLUSIONS: More robust studies of the association between self-evaluation and depression in adolescents with a chronic illness is needed, with attention to the nuances of differences between chronic illnesses. The existing evidence indicates that there may be a stronger association in some chronic illnesses. Pilot data suggest that specific psychological therapies may improve self-evaluation, although much more extensive evaluation is needed.

Nonpharmacological interventions for treating fatigue in adolescents: A systematic review and narrative synthesis of randomised controlled trials.

OBJECTIVE: Fatigue is common in adolescence and can be highly disabling if experienced persistently, with adverse psychosocial outcomes. There is a need to better understand what nonpharmacological treatments are available for adolescents suffering with persistent fatigue. The current review systematically identified, synthesised, and evaluated the evidence regarding nonpharmacological interventions for fatigue in adolescents, focusing on evaluating effectiveness, describing intervention components, and mapping interventions onto the behaviour change technique taxonomy (BCTT). METHODS: CENTRAL, EMBASE, PsycINFO, PubMed, and Web of Science were systematically searched for articles including (1) adolescents aged 10-19 years old, (2) fatigue as a primary or secondary outcome, (3) nonpharmacological interventions, and (4) randomised controlled trials. Study screening, data extraction, quality assessment, and BCTT mapping were performed independently by two reviewers. Findings were presented as a narrative synthesis, with interventions ranked by promise. RESULTS: 5626 papers were identified and double-screened, resulting in the inclusion of 21 articles reporting 16 trials. Five interventions were classified as likely promising. Interventions often involved psychoeducation, cognitive behavioural therapy, and/or physical activity, incorporating various BCTT domains, most commonly shaping knowledge, repetition and substitution, and goals and planning. However, there did not seem to be any observable differences between fatigue-targeted and non-fatigue-targeted interventions. Overall study quality was mixed, particularly in relation to power and outcome measures. CONCLUSION: There are several promising nonpharmacological interventions for adolescent fatigue, although further work is needed to determine effectiveness. Future trials need to ensure design rigour, focusing on adequate powering, validated outcome measures, and adhering to best practice reporting guidelines.

4 Steps To My Future (4STMF): protocol for a universal school-based pilot and feasibility study of a CBT-based psychoeducational intervention to support psychological well-being amongst young adolescents in the Western Cape, South Africa.

BACKGROUND: Mental health problems often emerge during middle childhood and adolescence. In South Africa, and in the context of high rates of poverty, violence, and adversity, many children are at a considerable risk for developing mental health problems. Access to and costs of mental health services preclude treatment for most. There is evidence that universal school-based prevention programmes are effective in well-resourced settings. However, little is known about the feasibility and acceptability of such programmes in low- and middle-income countries (LMICs), including South Africa. METHODS: This is a feasibility pilot study of 4 Steps To My Future (4STMF), a Cognitive Behaviour Therapy (CBT) school-based programme for young adolescents in the Western Cape, South Africa. This eight-session intervention will be delivered to children in grade 5 (aged 10-13 years approximately) attending two public government-run schools in the Western Cape, South Africa. We aim to enrol approximately 224 children in grade 5. We will randomise which school receives the intervention first and the other will be a delayed intervention group. We will train individuals with a post-graduate degree in psychology to facilitate the programme. We will collect demographic data on participants as well as data on primary (feasibility measures) and secondary outcomes (mental health and well-being measures). We will collect data at baseline, post-intervention, and at 1-month follow-up. DISCUSSION: This pilot study will provide data on the acceptability and feasibility of delivering a universal school-based prevention programme in South African schools. The study will provide preliminary data to inform the design of a full-scale randomised controlled trial (RCT) of a universal school-based mental health programme aimed at preventing mental health problems. TRIAL REGISTRATION: This trial is registered with the Pan African Clinical Trial Registry ( https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=10881 ) database, with unique identification number for the registry: PACTR202004803366609. Registered on 24 April 2020.

Parental Experiences of Adolescent Cancer-Related Pain: A Qualitative Study.

OBJECTIVE: Despite advancing medical treatments, pain remains a significant outcome of adolescent cancer, as both a problematic and distressing symptom. With adolescents spending substantial periods of time at home during cancer treatment, parents perceive themselves as central to the experience and management of adolescents' pain. The present study aimed to explore parental experiences of adolescent cancer-related pain during, and recently after, completing cancer treatment. METHODS: We interviewed 21 parents of adolescents (aged 12-18 years) with cancer, recruited through a hospital in South West England. Interviews were analyzed using reflexive inductive thematic analysis. RESULTS: Two themes were generated. The first theme, "Parental perceptions of being at the heart of pain management," focused on the role of parents in adolescents' pain journeys, and the vast knowledge they gained. The second, "Adapting and readjusting expectations," captured parents' journeys in learning to adjust their lives according to adolescents' pain and difficulties they faced throughout this process. CONCLUSIONS: Findings highlighted parents' crucial role throughout adolescents' pain experiences; learning how to manage adolescents' pain, and supporting them with the detrimental impact on their lives. The findings emphasize the importance of a multidisciplinary approach to supporting families to manage pain. They also indicate a need for targeted research studies investigating parental experiences of adolescent cancer-related pain. This will help professionals understand how best to support parents and adolescents throughout the cancer journey and ultimately improve the physical and psychological outcomes of young people in the longer term.

South African youth's understanding of feelings, thoughts and behaviours: Implications for the development of CBT-based mental health interventions.

BACKGROUND: Mental health problems are common in youth in low- and middle-income countries (LMICs), including South Africa. Preventative interventions, based on cognitive behaviour therapy (CBT), delivered in schools, have been found to alleviate symptoms of depression and anxiety in high income countries (HICs). However, less is known about whether youth in LMICs are able to engage with the core concepts of CBT. AIMS: To explore how young people in the Western Cape, South Africa, understand key CBT concepts, such as feelings, thoughts and behaviours. METHOD: We interviewed 22 young people (10-15 years of age; mean age 11.6 years; SD = 1.0) recruited from two public primary schools in the Western Cape, South Africa. Interviews were audio-recorded, transcribed verbatim, translated from Afrikaans into English where necessary and analysed thematically using a deductive approach. RESULTS: Young people described feelings as internal, private, and should only be shared with trusted others. They also described how feelings varied, depending on the situation. They found the concept of thoughts more challenging to describe. Youth were able to say what they do when they experience unpleasant feelings, and they linked their behaviours to their feelings and thoughts. CONCLUSIONS: In this cultural context, our qualitative investigation found evidence that young people were able to engage with abstract concepts including feelings and to some degree, thoughts. To ensure that CBT-based interventions are developmentally appropriate and accessible, psychoeducation may help youth distinguish between thoughts, feelings and behaviours, and a focus on identifying and naming feelings may be beneficial.