Imaginative play for inclusion: Evaluating the Young Dragons tabletop role-playing intervention in UK schools

Imaginative play for inclusion: Evaluating the Young Dragons tabletop role-playing intervention in UK schools | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Imaginative play for inclusion: Evaluating the Young Dragons tabletop role-playing intervention in UK schools Austen El-Osta, Yiran Li, Sami Altalib, Aos Alaa, Rebecca Linsley, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8357803/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background School exclusion in England disproportionately affects pupils with social, emotional, and mental health needs. Tabletop roleplaying games (TTRPGs) may strengthen social emotional learning but are rarely evaluated in UK state schools. Young Dragons, a Dungeons & Dragons based programme, was developed to support emotional regulation, teamwork, and engagement among pupils at risk of exclusion in two London boroughs. Methods A convergent mixed methods realist evaluation was delivered across ten schools. Pupils aged 9–16 attended weekly one-hour sessions for 6–8 weeks in small, consistent groups. Pre/post pupil surveys captured wellbeing, self-concept, peer relations, school belonging, and loneliness; matched pair change (n = 22) used Wilcoxon signed rank tests. Semi-structured interviews with school staff and facilitators and observation of multiagency meetings explored implementation and perceived impact. Findings were integrated using joint displays and context–mechanism–outcome (CMO) mapping. Results No statistically significant within person change was detected across matched items (all p > 0.10). Distributions showed heterogeneous trajectories: many pupils reported better mood, anger regulation, and confidence, while a minority shifted toward greater disengagement or loneliness. Exploratory analysis of routine school records (n = 30) showed a significant reduction in mean suspensions from 0.7 pre-intervention to 0.0 post-intervention (p = 0.022) and a modest, non-significant increase in mean attendance from 90.6% to 92.7% (p = 0.069). Qualitative accounts described strong engagement, psychological safety, and visible gains in self-management, turn taking, and teamwork, with positive spillover into classroom behaviour when groups were stable and facilitation was consistent. Delivery challenges included timetable pressures, space constraints, and stigma around targeted provision. Integration identified skilled facilitation, small-group safety, and structured reflection as key mechanisms enabling co-regulation, perspective taking, and belonging. Conclusion Young Dragons was feasible and acceptable in high need school settings. Benefits were mechanism-consistent for many participants but contingent on context and facilitator quality. These pilot data justify a larger, controlled evaluation to test causal pathways and longer-term outcomes for inclusion and emotional wellbeing. tabletop role-playing games (TTRPG) Dungeons & Dragons social and emotional learning (SEL) school exclusion emotional regulation inclusion adolescent mental health mixed-methods evaluation realist evaluation self-management teamwork narrative-based intervention at-risk pupils UK schools Figures Figure 1 Figure 2 Figure 3 Introduction School exclusion is a persistent educational and public health concern in England with consequences that extend across the life course( 1 , 2 ). Pupils who are suspended or permanently excluded are more likely to experience poor mental health, low attainment and later contact with the criminal justice system( 2 – 4 ). Recent national figures indicate record levels of suspensions and permanent exclusions, with local patterns that are unequally distributed and concentrated among children already facing adversity, including those with special educational needs and disabilities and those living in poverty( 5 , 6 ). In Westminster and the Royal Borough of Kensington & Chelsea (RBKC), exclusion rates have at times exceeded London averages and are concentrated in the most deprived wards( 6 , 7 ). Schools in these boroughs also contend with high proportions of pupils eligible for free school meals, substantial linguistic diversity and rising demand for mental health support( 8 – 12 ). The public health and equity implications are clear: exclusion is not simply a disciplinary endpoint, but a marker of unmet social, emotional and mental health (SEMH) need and local education systems require preventative, inclusive responses that can be delivered within the everyday ecology of schools( 1 ). Against this backdrop, there is growing interest in creative, low stigma, play based interventions that can strengthen social–emotional learning (SEL) while engaging pupils who may be ambivalent toward conventional support( 13 – 15 ). Tabletop roleplaying games (TTRPGs), notably Dungeons & Dragons (D&D), have emerged internationally as promising tools for cultivating communication, collaboration, perspective taking and problem-solving( 14 ). Yet their application in UK state schools remains rare, the evidence base is thin in formal education settings and, crucially, little is known about how such programmes are experienced and implemented in real classrooms serving diverse, high need cohorts The theoretical appeal of TTRPGs for SEL lies in the way structured narrative, rules and collaboration combine to create psychologically safe conditions for social risk taking and identity work( 16 , 17 ). In D&D, pupils adopt characters, co-create stories, negotiate choices and contend with consequences inside a rule governed, facilitator led environment( 16 – 18 ). These mechanics align with the five competencies in the CASEL framework self-awareness, self-management, social awareness, relationship skills and responsible decision making by requiring turn taking, empathic perspective taking, conflict navigation and reflective decision making in a shared enterprise( 19 , 20 ). The format also supports coregulation: pupils practise sharing the spotlight, reading group norms and making joint plans, while the rules scaffold fairness and predictability( 17 , 18 ). In short, the game world functions as a “safe laboratory” where pupils can rehearse different versions of themselves and transfer emerging skills into everyday school life( 16 ) Although therapeutic and community studies have reported improvements in anxiety, self-esteem, social connection and teamwork associated with TTRPG participation, the translation of these gains into mainstream UK schools and the conditions that enable or constrain them remain underexamined( 15 , 17 , 19 , 21 , 22 ). Teachers’ perspectives are especially underrepresented despite teachers’ pivotal role in observing day-to-day behaviours, judging acceptability and brokering practical fit with timetables, staffing and safeguarding routines( 19 ). Recent qualitative work embedded in central London schools suggests teachers observe changes across all five CASEL domains when TTRPG programmes are delivered in small, supported groups, but also identifies salient implementation questions: who benefits, under what conditions and how can delivery be sustained at scale without diluting quality The Young Dragons pilot was designed to address these questions in real school contexts. Commissioned by the BI Borough Children’s Services and delivered with Mythic Minds CIC across ten state schools in Westminster (WCC) and RBKC, the programme targeted pupils aged 9–16 identified by school staff as at risk of exclusion, socially isolated, or experiencing SEMH difficulties. Delivery consisted of weekly one-hour sessions over six to eight weeks in small, consistent groups of four to six pupils, facilitated by trained “storytellers” with school staff present in a supervisory or co-facilitative capacity. The core pedagogical logic combined imaginative play, cooperative problem solving and structured reflection, with the intention of building trust, communication, self-regulation and a sense of belonging. In practice, delivery had to accommodate the variability that typifies urban schooling: timetable pressures, room availability, attendance fluctuations, group composition and the need to adapt scenarios to the developmental stage and diversity of each cohort. The primary aim of this realist evaluation is to assess the impact of the Young Dragons programme on the emotional wellbeing, social communication and school engagement of pupils aged 9–16 identified as at risk of exclusion or experiencing SEMH needs. Specifically, the evaluation sought to: (i) explore changes in self-esteem, emotional regulation and perceived school belonging because of programme participation, (ii) gather pupil-reported experiences of loneliness and inclusion before and after the intervention, (iii) identify delivery challenges and contextual factors influencing programme fidelity, engagement and acceptability and (iv) generate recommendations for refinement, scalability and future implementation across similar school settings. Methods Study design This was a convergent mixed methods evaluation with a realist orientation, conducted as pre-post pilot in mainstream, through secondary and alternative provision schools in WCC and RBKC. The design was pragmatic, chosen to test feasibility and acceptability under real delivery constraints, to describe within person change in key social emotional domains and to develop explanatory accounts of how context and mechanisms conditioned outcomes. The mixed methods frame enabled parallel quantitative and qualitative analyses followed by structured integration to build context–mechanism–outcome (CMO) propositions. Reporting follows GRAMMS for mixed methods, STROBE for the quantitative observational component, COREQ for the qualitative interviews and RAMESES II for realist logic, with TIDieR informed description of the intervention components. Setting, participants and recruitment The intervention ran across ten state funded schools spanning primary, secondary, an all through academy and a pupil referral unit. School inclusion reflected the local mix of high deprivation, elevated free school meal eligibility, substantial proportions of pupils using English as an additional language and rising presentations of social, emotional and mental health need. Pupils aged 9–16 were nominated by special educational needs coordinators, heads of year, or inclusion leads based on observed risk of exclusion, SEMH challenges, social isolation, or disengagement. Exclusion criteria were minimal and limited to acute risk or placement in intensive specialist provision. Groups were kept small (typically 4–6) and pupils remained with the same peers to support cohesion, trust and narrative continuity. School staff were present during sessions in a supervisory or facilitative role. Intervention Young Dragons comprised weekly one-hour sessions of the tabletop roleplaying game Dungeons & Dragons for six to eight weeks, delivered on school premises by trained facilitators from the social enterprise Mythic Minds CIC. Sessions followed a consistent arc of check-in and recap, facilitated narrative play, cooperative problem-solving and guided debrief with explicit links to emotions, group process and transfer to school life. The format leveraged structured rules, turn taking, character perspective taking and collective decision-making to exercise competencies aligned with the CASEL framework (self-awareness, self-management, social awareness, relationship skills, responsible decision making). Scaffolding and scenario complexity were adjusted to age, literacy and group dynamics. Fidelity was supported by facilitator supervision and weekly debriefs, while adaptation to timetable and space constraints preserved ecological fit. Quantitative measures and data collection Pupil reported outcomes were collected immediately before the first gaming session and after the final session using a bespoke, age-appropriate survey codeveloped with educators and the delivery partner. Items captured emotional wellbeing, self-concept and confidence, emotional regulation (stress, anger control, feeling control), social communication and peer support, loneliness (direct measure) and school engagement (belonging and enjoyment). Response formats used simplified Likert scales and emoji aided anchors to enhance accessibility. Free text questions captured brief reflections. To preserve anonymity while enabling linkage, pupils used pseudonymous “hero names”; manual reconciliation of minor spelling variants was undertaken to maximise match accuracy. Surveys were administered in class time as paper or online forms with adult support when required. Data quality screening excluded test entries, nonconsent and irreconcilable records. The survey was disseminated on the Qualtrics XLM platform. The electronic survey is included in Supplementary File 1 . Quantitative analysis Descriptive statistics using frequencies and percentages summarised response distributions at each timepoint across domains for all available cases. Pre–post within person change for matched pairs was estimated using the Wilcoxon signed rank test for ordinal outcomes, reporting p-values and signed Z statistics. Statistical significance was set at 0.05. Data was analysed using STATA 18 STATA, version 18 (StataCorp LP, College Station, TX, USA). Qualitative design, sampling and data collection The qualitative strand adopted an interpretivist approach to capture the experiences of those closest to delivery, focusing on teacher perspectives on pupil change, implementation enablers and barriers and prospects for sustainability. Semi structured interviews were conducted with nine participants comprising school-based staff and facilitators; interviews lasted approximately 20–45 minutes, were held via Microsoft Teams and followed a topic guide covering general impressions, perceived impact across SEL domains, practicalities of delivery and future relevance. In parallel, nonparticipant observation of three multiagency steering group meetings provided contextual insight into coordination, adaptive strategies and process learning across sites. With consent, interviews were audio recorded for verbatim transcription; identifiable details were pseudonymised. Field notes from observations were recorded systematically; to reduce reactivity, direct session observation was avoided when it inhibited pupil spontaneity, with the team privileging post session debriefs for richer, less intrusive insight. Qualitative analysis Transcripts were imported into NVivo 14 and analysed using thematic analysis following Braun and Clarke’s six phase procedure. Coding was inductive and data driven in the first cycle to preserve participants’ language and local meaning, with iterative development of candidate themes capturing pupil level changes, group dynamics, facilitation and organisational conditions. In a second analytic pass, themes were mapped onto the CASEL framework to identify which competencies were most salient and to test alignment between reported changes and the programme’s theory of change. Observational notes were not formally coded but were used for triangulation and to refine theme boundaries and interpretations. Analytic memos recorded decisions, reflexive considerations and deviant cases. COREQ informed documentation of researcher roles, data saturation rationale and procedures to enhance trustworthiness. Mixed methods integration and realist synthesis Integration used a convergent design in which quantitative and qualitative strands were analysed independently and then brought together through joint displays and realist pattern matching. Joint displays aligned pre–post distributions and matched pair change patterns by domain with illustrative teacher quotations and facilitation narratives, enabling inspection of convergence, complementarity, or divergence. A realist heuristic guided the development of CMO propositions. For example, small, stable groups led by skilled facilitators (context) appeared to trigger coregulated play, perspective taking and collaborative problem solving (mechanisms), which for pupils with high baseline dysregulation manifested as improved anger control, teamwork and confidence (outcomes); conversely, timetable pressure, space changes, or unfamiliar adults (context) appeared to blunt engagement and attenuate gains in school belonging (outcome). Integration outputs were used to refine practical guidance and to specify testable hypotheses for future controlled or stepped wedge evaluations. Reporting standards and methodological frameworks This study was designed and reported in accordance with established reporting and methodological guidance appropriate to each component of the evaluation. The quantitative observational component followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The qualitative interview component was reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Integration of quantitative and qualitative findings followed the Good Reporting of A Mixed Methods Study (GRAMMS) framework. Given the programme’s theory-driven, explanatory focus, a realist orientation was adopted to explore how outcomes varied by context. Development and reporting of context–mechanism–outcome (CMO) configurations were informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES II) guidance. Description of the Young Dragons intervention and its delivery was structured using the Template for Intervention Description and Replication (TIDieR) checklist to support transparency and replicability. Completed STROBE and COREQ checklists are provided as supplementary materials ( supplementary files 2 and 3 respectively) Results Participants and data completeness. Across ten schools, 86 pupil surveys were collected between May-July 2025. After data quality checks (removal of test entries, non-consent and irreconcilable identifiers), 50 baseline and 36 post-intervention surveys were retained. Of these, 22 pupils could be matched pre-post using pseudonymous “hero names.” Interview data comprised nine semi-structured interviews with school staff and facilitators, alongside non‑participant observations from three multi‑agency steering group meetings. No adverse events were reported. The Main survey findings are illustrated in Supplementary Table 1 . Changes in Students’ Wellbeing and Self-Perception Distributions at the group level were broadly stable but showed visible polarisation on several items. For overall mood (“How is everything going?”), the most positive category remained high (46.0% at baseline versus 50.0% post), while the most negative category emerged at follow-up (0.0% to 13.9%). School engagement showed a similar bifurcation: “😊👍👍” was 32.0% at baseline and 33.3% post, but “☹ฏ👎👎” increased from 2.0% to 16.7%. Self-concept showed mixed movement: endorsement of “I have a number of good qualities” increased in the “agree/strongly agree” range (66.0% to 69.5%) and “unsure” declined (22.0% to 13.9%), yet “I feel good about myself” saw “strongly disagree” rise (6.0% to 16.7%). For emotional regulation, anger control shifted positively (“true” 14.0% to 27.8%, “very not true” 24.0% to 11.1%), whereas stress coping remained challenging, with high “unsure” at both timepoints. Loneliness “often/always” rose from 2.0% to 8.3%. School belonging remained mostly moderate to high, but “not at all true” increased (12.2% to 19.4 % ); Supplementary Table 1. Quantitative outcomes Matched-pair analysis of 22 pupils showed no statistically significant changes across any primary outcome items (Table 1 and Fig. 1 ). However, directionally, several domains suggested small improvements after the intervention. General self-assessment (“How are you doing?”) showed the largest positive shift (Z = − 1.777, p = 0.107), indicating higher post-intervention ratings. Measures of competence (“I am able to do things as well as most other people”) and personal qualities also trended upward (Z = 1.635 and 1.448, respectively). Indicators related to mood, school belonging, and social relationships remained broadly positive and stable from baseline to follow-up. Family relationships continued to score highly, with no deterioration observed. Measures of emotional control and stress coping showed small, non-significant fluctuations, suggesting overall stability rather than decline. While statistical significance was not achieved, descriptive trends indicated modest improvements in self-perceived competence, self-assessment, and peer support following the intervention. The pattern is consistent with feasibility-focused inference and heterogeneous trajectories rather than uniform group-level change. Table 1 Matched pair Wilcoxon signed rank tests for primary outcome items (n = 22). All p > 0.10; negative Z indicates higher post scores on items framed positively and vice versa as reported in the source table Domain / Item Z p General mood “How is everything going?” −0.684 0.541 School engagement “How are you doing at school?” 0.950 0.371 Family relationships “How are things in your family?” −0.898 0.406 General self-assessment “How are you doing?” −1.777 0.107 Satisfaction with self “I am satisfied with myself” 0.404 0.684 Personal qualities “I have a number of good qualities” 1.448 0.213 Competence “I am able to do things as well as most other people” 1.635 0.118 Feeling good about oneself “I feel good about myself” −0.409 0.722 Control over feelings “I find it hard to control my feelings” 0.456 0.714 Stress-coping “I’m able to deal with stress” −0.503 0.664 Anger control “I can control my anger when I want to” −0.168 0.871 Getting along “I get along with people around me” −0.779 0.508 Being liked “People like to spend time with me” −1.219 0.307 Friend support “I feel supported by my friends” −0.663 0.617 Friends’ care “My friends care about me when times are hard” −0.610 0.727 Turn-taking “I take turns when playing games with others” −0.207 0.899 Loneliness “How often do you feel lonely?” 0.480 0.694 School belonging “I feel like I belong at my school” −1.051 0.366 Enjoyment of school “I enjoy coming to school” −0.551 0.563 Responder heterogeneity Aggregated counts show concurrent improvements and deteriorations within the same cohort, highlighting nonuniform response (Table 2 ). For example, for overall mood, 6 pupils improved, 12 were unchanged and 4 worsened; for school engagement 5 improved and 8 worsened; for competence self-appraisal 11 improved and 5 worsened; for anger control 7 improved and 8 worsened. For items where “higher” reflects more difficulty (“hard to control my feelings”; loneliness), worsened counts capture movement toward greater difficulty. These distributions support a three-way typology suggested by the descriptive data: pupils who improved on several domains, pupils who remained broadly stable and pupils who shifted toward more negative responses postintervention. This structure is not visible in central tendency but is evident in category movement and individual trajectories. Key demographic data from the 10 participating schools is shown in Table 3 below. Across 30 matched pupils with attendance and suspension data, mean attendance increased from 90.6% to 92.7%, although this did not reach statistical significance (p = 0.069). Importantly, mean suspensions declined significantly, from 0.7 pre-intervention to 0.0 post-intervention (p = 0.022). From the data, a three-way typology of impact can be inferred (Fig. 2 ). The presence of all three groups is a hallmark of early-stage, creative mental health programmes delivered in real-world, high-need school contexts. A confusion matrix (Fig. 3 ) provides a visual synthesis of paired participant feedback across key domains of the Young Dragons intervention. The matrix provides a visual synthesis of paired participant feedback across key domains of the Young Dragons intervention. Colours denote the nature of responses (positive, neutral, or negative), enabling at-a-glance comparison across participants and domains. Green denotes a Positive response (clear evidence of improvement or benefit), Amber denotes a neutral/mixed response (limited change or varied perspectives), Red denotes a negative response (no improvement or reported concern). Table 2 Paired response change counts by item (n = 22) Item (paired analysis) Improved No change Worsened How is everything going? 6 12 4 How are you doing at school? 5 9 8 How are things in your family? 4 16 2 How are you doing? 8 12 2 I am satisfied with myself 5 13 4 I have a number of good qualities 9 9 4 I am able to do things as well as most other people 11 6 5 I feel good about myself 6 9 7 I find it hard to control my feelings* 6 8 8 I’m able to deal with stress 9 7 6 I can control my anger when I want to 7 7 8 I get along with people around me 5 14 3 People like to spend time with me 8 10 4 I feel supported by my friends 6 12 4 My friends care about me when times are hard 5 14 3 I take turns when playing games with others 6 10 6 How often do you feel lonely?* 6 9 7 I feel like I belong at my school 9 9 4 I enjoy coming to school 6 14 2 Total 127 200 91 *Higher post values on these items indicate greater difficulty (worse outcome). Table 3 Participating school demographic data School Name % FSM Eligible % SEND Support % SEN Education, Health & Care Plan (EHCP) % Pupils 1st language not EN (2023/24) % Suspension Rate (2023/24) RBKC St Francis of Assisi RC primary school 47.8% 15.6% 6.1% 39.7% 0.0% Servite RC primary school 20.5% 17.0% 5.5% 54.6% 0.0% Avondale Park primary school 49.5% 23.4% 5.5% 66.6% 8.8% Holland Park School 30.5% 13.6% 4.1% 36.3% 10.2% Kensington Aldridge Academy 54.3% 13.6% 7.1% 44.1% 22.1% WCC Gateway Primary 51.7% 13.0% 4.6% 89.8% 0.7% Queen’s Park Primary 47.7% 8.6% 10.5% 70.3% 1.1% King Solomon Academy 64.2% 18.6% 2.3% 66.0% 15.2% Westminster Academy 48.3% 15.0% 2.7% 56.2% 27.1% St Marylebone CofE School 22.0% 10.0% 3.0% 29.0% 2.5% Qualitative outcomes This study explored the perceptions of educators, programme staff and a parent involved in the D&D pilot. A total of 7 interviews were conducted between 11 and 21 July. Participant characteristics are shown in Table 4 . Table 4 Participant characteristics Participant role School Other notes N. Commissioners & Programme Leads NA Included commissioners, public health, programme managers 6 Mythic Minds CiC Intervention leads NA Deep overview of delivery of intervention 2 Pastoral support worker Westminster Academy Substituting for Y7 colleague, direct observations + staff feedback 1 Learning Support Assistant (LSA) St Marylebone High School Attended all but one session, participant-observer 1 Parent of pupil / School admin staff Avondale Park Primary Parent of pupil with SEND; also worked in school office 1 School learning mentor (teacher) Avondale Park Primary Accompanied children in the games sessions, witnessed increase in turn-taking, better collaboration as the imitative progressed 1 Headteacher St Francis of Assisi Primary School Did not attend sessions but spoke to children before and afterwards and engaged with the storyteller after the sessions 1 Headteacher Queen’s Park Primary Attended sessions and observed increase in confidence and turn taking. Being able to advocate for themselves. 1 Co-Head teacher with responsibility for children with additional needs Gateway Academy (primary) Accompanied children, witnessed improvement in turn taking, improved social interaction 1 Five overarching categories emerged, capturing socio-emotional gains, confidence & self-expression, social connection, creativity and implementation factors. These qualitative findings help contextualise the quantitative results, highlighting how the programme influenced pupils and the conditions that supported or constrained its delivery. Several themes emerged from the interviews which could be grouped into five categories (Table 5 ). Table 5 Summary of qualitative themes from Young Dragons evaluation Category Themes Subthemes Engagement & initial perceptions Excitement & curiosity about D&D Staff curiosity; novelty of approach; relevance to pupils already interested in D&D Positive reception & buy-in Early enthusiasm from pupils; rapid engagement; willingness to try Parental perceptions & consent Face-to-face & email communication; initial scepticism vs later support Social interaction & peer relationships Intra-group dynamics Bonding across classes; teasing & camaraderie; handling interpersonal conflict Collaboration & teamwork Turn-taking; listening skills; problem-solving together Cross-cultural exchange Learning from culturally diverse peers; inclusive participation Personal development & behavioural change Emotional regulation Calmer behaviour; self-control; fewer behavioural incidents Self-management Improved lesson readiness; reduced exclusions; better instruction-following Confidence & self-expression Increased social participation; role-play enabling safe expression Perspective shifts Changes in perception of authority figures; feeling understood Facilitator & programme design factors Skilled facilitation Enthusiastic, informal, and structured leadership Structure & pacing Breaking tasks into steps; clear expectations; safe environment Optimal conditions Appropriate age groups; session length; number of participants Outcomes, sustainability & unintended effects Positive spillover Improved relationships outside the game; parental observations of home behaviour Unintended outcomes Strengthened adult–student rapport; peer fallouts unrelated to programme Sustainability & scalability Need for longer interventions; expansion to more pupils; integration into wider wellbeing strategies Teacher and facilitator accounts converged on strong engagement, small group safety and gains in self-management, teamwork, confidence and social connection for many participants, with variability linked to facilitation, group composition and scheduling. Staff described shifts from competition to collaboration (“ ‘I want to go first’… now they understand they have to take turns, they have to work as a team” ), improved emotional regulation (“being able to stop, understand and follow instructions”) and increased confidence and voice among previously quiet pupils (“ he’s very vocal… speaks with a louder voice and his head held up high”). A parent who was also a member of staff in a participating school noted spillover beyond sessions (“ he was quite calm… he listened and engaged”; “even at home he was more compliant”). The D&D format was viewed as therapeutic without stigma, combining structure and imaginative freedom in a psychologically safe space, though early hesitancy, selection stigma and timetable/resource constraints were reported. Facilitator skill was repeatedly identified as critical to holding boundaries, pacing narratives and adapting challenges to developmental level. Mapping of interview material to CASEL competencies indicated the most salient domains were self-management (eight instances) and relationship skills (seven), followed by responsible decision making (four), with fewer explicit references to self-awareness and social awareness (two each). This profile mirrors the quantitative signals in anger control, peer support and cooperation. Stakeholders expressed a desire to continue and expand provision, paired with recognition that sustainability will require predictable scheduling, dedicated space and capacity building for trained delivery. Mixed methods integration The integrated joint displays aligned three recurrent quantitative and qualitative patterns. First, improved anger control and cooperation for a substantial subgroup cooccurred with teacher observed coregulation and turn taking in small, stable groups led by skilled facilitators. Second, stable or strengthened belonging and enjoyment for many pupils coexisted with a minority shift toward low categories; interviews attributed the divergence to timetable pressure, unfamiliar adults and space changes that blunted engagement. Third, modest gains in competence self-appraisal and “good qualities” mapped to vignettes of confidence and leadership emergence, especially among previously withdrawn pupils, while the small rise in strong negative self-appraisals was interpreted as increased self-reflection for a few. These patterns support provisional context–mechanism–outcome propositions to be tested in a longer follow up: small, consistent groups and skilled facilitation (context) trigger coregulated play and perspective taking (mechanism), producing improved self-management and teamwork (outcome); delivery instability (context) dampens the same mechanisms, attenuating belonging and engagement (outcome). A systematic review of the transcripts identified 8 instances of self-management, 7 of relationship skills, 4 of responsible decision-making, 2 of social awareness and 2 of self-awareness. These counts represent explicit, observable behaviours or reflections aligned with each CASEL competency and provide insight into the areas where the programme’s impact was most evident. Table 6 presents a representative quote from each CASEL domain including the relative frequency of each competency observed in the dataset. Table 6 Quote matrix and frequency distribution (CASEL framework) Competency f Theme Quote Source Self-awareness 2 Recognizing emotions and strengths One student said that they believed that “my self-management has improved, and I can see it…” What they lacked was being able to regulate their emotions, being able to stop, understand and follow instructions. Westminster Academy Self-awareness Reflecting on self through role-play They said, “It was the highlight of my week…” It was an opportunity for them to express themselves in a safe environment through a character… and learn how that impacts other people. Learning support assistant ‚ St Marylebone Self-management 8 Improved emotional regulation In the very beginning they would argue‚ but now they understand they have to take turns, they have to work as a team using their confidence in wanting to work together rather than against each other. Westminster Academy Transfer of regulation skills to home Even at home‚ they are more compliant and better at understanding instructions. Parent feedback via Westminster Academy Social awareness 2 Empathy and cross-group interaction He was more social in that group… he spoke to children from the other class. He was excited about it. Parent at St Francis Appreciating different perspectives It captured their imagination‚. It allowed expression and imagination to flourish. Learning support assistant, St Marylebone Relationship skills 7 Improved peer-staff relationships One student I really speak to me at all, Now she waves, engages in conversation, is friendly. Learning support assistant, St Marylebone Positive facilitation and group cohesion Rupert was very good. He was skilled at being friends with the girls, holding the game and making the experience enjoyable for everybody. Learning support assistant Marylebone Responsible decision-making 4 Making constructive choices Sometimes they might use that confidence to say what’s on their mind happen, allowing them to step into the right places. Westminster Academy Collaborative problem-solving They had to fi figure out how to get back from the island. Him and his friend done it together. Parent at St Francis Discussion Principal findings This convergent realist mixed-methods pilot evaluated the Young Dragons tabletop role-playing intervention for pupils at risk of exclusion across ten state schools in WCC and RBKC. Quantitative results did not show any statistically significant average pre-post changes across matched pairs, yet distributions showed simultaneous improvement and deterioration in emotional wellbeing, self-concept, anger control and school belonging. In addition to pupil-reported outcomes, routine school records provided a complementary behavioural signal. Across 30 matched pupils with available attendance and suspension data, mean attendance increased from 90.6% to 92.7% over the intervention period, although this change did not reach conventional statistical significance (p = 0.069). More notably, mean suspensions declined significantly from 0.7 pre-intervention to 0.0 post-intervention (p = 0.022). While these findings should be interpreted cautiously given the small sample and short follow-up, they are directionally consistent with staff accounts describing calmer behaviour, improved emotional regulation and fewer behavioural escalations during and after sessions. Within a realist interpretation, these patterns suggest that the programme may exert indirect effects on behavioural stability through mechanisms of co-regulation, turn-taking and increased psychological safety, even over a brief delivery window. This quantitative signal aligns with school narratives describing calmer behaviour, improved regulation and fewer behavioural escalations. Qualitative accounts described strong engagement, psychological safety and visible gains in self-management, teamwork and peer connection for many participants, alongside implementation challenges related to scheduling, space and facilitator stability. Integration of both strands supports a mechanism-based interpretation- that outcomes were conditioned by context and facilitation rather than uniform programme effects. Collectively, these findings strengthen the case that Young Dragons may indirectly support attendance and behavioural stability even within a short timeframe Interpretation of quantitative and qualitative results The absence of statistically significant mean change reflects the design and sample rather than lack of impact. With only 22 matched pairs and a six-to-eight-week exposure window, the analysis was under-powered for conventional significance testing. However, the directionality of change and category shifts point to a phenomenon of polarisation, typical in developmental and psychosocial pilots where some pupils thrive while others show transient discomfort or disengagement. Teachers and facilitators described the same heterogeneity: pupils who entered sessions withdrawn often became more expressive and cooperative, while a smaller subset appeared unsettled by introspection or the unstructured nature of imaginative play. The programme’s mechanisms narrative immersion, cooperative rule-based interaction and structured reflection appear to benefit pupils ready for social learning, while those with unresolved distress or unstable attendance may require longer exposure and additional containment to avoid reactive stress. This nuanced picture illustrates why early-stage, creative interventions should be interpreted through a realist rather than positivist lens. Mechanisms of change Findings align closely with the intervention’s theory of change and with SEL scholarship. The Young Dragons format created a predictable, rule-governed micro-community that exercised the CASEL competencies: (i) Self-management emerged through anger control, turn-taking and behavioural regulation; (ii) Relationship skills through collaboration and empathy in shared quests, (iii) Self-awareness through character creation and “safe self-projection” and (iv) Responsible decision-making through simulated moral and strategic dilemmas. Teachers linked positive behavioural changes to these mechanisms, noting calmer classroom conduct and renewed confidence among participants. Where the setting was disrupted by room changes, timetable clashes, or untrained facilitators the same mechanisms were blunted and pupils’ sense of belonging declined. In realist terms, the context (stable group, skilled facilitator, consistent space) triggered mechanisms of co-regulation and perspective-taking that yielded positive outcomes, while adverse contexts interrupted these chains. Comparison with existing evidence The findings corroborate international literature demonstrating TTRPGs can enhance social confidence, empathy and teamwork through narrative collaboration( 21 ). Studies in therapeutic and community settings have reported reduced anxiety and improved self-esteem after Dungeons & Dragons interventions( 17 , 21 ). Similar school-based experiments in Australia and North America show increases in communication skills and prosocial behaviour( 23 – 25 ). The present study extends this evidence into the UK state-school context and adds teachers’ perspectives, which are scarce but essential for implementation science( 19 ). Unlike earlier research in after-school or clinical environments, this pilot occurred during standard timetable hours, within high-need urban schools characterised by linguistic diversity and resource constraints. That the intervention was both feasible and welcomed by staff indicates that TTRPG-based SEL programmes can translate beyond voluntary clubs into mainstream inclusion policy, provided their delivery is carefully scaffolded. Influence of local context WCC and RBKC present unique conditions for evaluating creative, low-stigma mental-health interventions. Despite their overall affluence, both boroughs exhibit high deprivation pockets, elevated free-school-meal eligibility and one of the highest proportions of pupils with English as an additional language in England. Demand for child mental-health services far exceeds capacity. In this environment, imaginative group interventions can offer accessible early support that complements overstretched specialist services. The pilot’s success in operating across ten schools demonstrates adaptability to these complex systems. However, logistical friction competing timetable priorities, room availability and fluctuating staff support significantly influenced outcomes. Such contextual realities reinforce that scalability depends not only on curriculum fit but also on administrative and infrastructural readiness. Implementation lessons The evaluation identifies several actionable levers for practitioners and commissioners. In terms of facilitation quality, teacher narratives converge on the importance of highly skilled facilitators able to manage behaviour, maintain narrative coherence and balance therapeutic empathy with classroom discipline( 26 ). Group size and consistency was also important as c ohorts of four to six pupils were optimal for engagement and safety. Larger or unstable groups risked dominance by a few voices and loss of trust. Environmental stability is deemed crucial as c onsistent time slots and dedicated rooms created predictability essential for pupils with SEMH needs( 27 , 28 ). Stigma-free recruitment was essential, including l abelling sessions as “creative storytelling” or “leadership” rather than “intervention” improved acceptability among families and pupils. Finaly, bridging to the classroom using structured reflection linking in-game behaviour to real-life contexts could strengthen skill transfer and allow teachers to reinforce lessons learned( 26 , 28 ). These levers correspond to known fidelity drivers in SEL implementation research and provide a roadmap for integrating TTRPG-based learning within inclusive-education strategies( 28 ). Strengths and limitations of the study The study’s strengths lie in its ecological validity and methodological integration. It was embedded in routine school practice, spanned multiple educational phases and engaged high-need populations under real delivery conditions. The convergent mixed-methods design allowed quantitative heterogeneity to be interpreted through qualitative mechanism analysis, preventing premature conclusions from under-powered statistical testing. The realist orientation generated explanatory hypotheses rather than binary verdicts and triangulation between teacher interviews, facilitator reflections and steering-group observations increased trustworthiness( 29 ). Finally, the study demonstrated that brief, child-friendly surveys can be administered feasibly in classroom settings to capture SEL-relevant constructs. The principal limitation of this study is the single-arm pre–post structure precludes causal inference; regression to the mean and concurrent school factors cannot be ruled out. The small matched-pair sample and attrition between timepoints reduce statistical power. Survey responses may reflect transient mood or social desirability, especially in multilingual cohorts with varying literacy. Ordinal scales compress variance and may not capture nuanced change. Exposure of only six to eight weeks may be insufficient for sustained social-emotional development and long-term outcomes remain unknown( 8 ). In the qualitative component, the necessity to avoid intrusive observation reduced opportunities for behavioural coding and inclusion of two facilitators among interviewees may have introduced positive bias( 30 ). Nevertheless, reflexive documentation and triangulation mitigated these risks. Overall, the evaluation should be viewed as a feasibility and mechanism study rather than a definitive test of effectiveness. Implications for theory The study adds to the theoretical understanding of how narrative play facilitates social-emotional learning. It supports models of co-regulated learning where structured fantasy environments allow pupils to practise emotional regulation and perspective-taking without real-world penalty. The observation of “polarisation” parallels developmental models in which increased self-reflection temporarily heightens distress before consolidation an effect reported in expressive and drama-based therapies. The realist CMO mapping derived here can inform refinement of programme theory: (i) Context: small, stable groups; skilled facilitation; consistent environment, (ii) Mechanism: co-regulated play, narrative identity exploration, perspective-taking and (iii) Outcome: improved self-management, confidence, teamwork and belonging. Conversely, when contextual supports weaken, mechanisms misfire, producing disengagement or transient distress. These propositions generate empirically testable hypotheses for the next stage of research. Policy and practice implications At policy level, Young Dragons aligns with the UK Government’s inclusive-education and mental-health-in-schools agendas. It operationalises prevention within the school day and demonstrates how public-health principles early intervention, low stigma and co-production can be applied through creative pedagogy. Commissioners seeking to reduce exclusions should consider TTRPG-based interventions as part of multi-tiered support systems, ensuring that procurement specifies facilitator qualifications, safeguarding standards and fidelity monitoring. For schools, embedding requires structural support: ring-fenced time, leadership buy-in and trained internal champions. Teachers involved in this study viewed the programme as complementing existing pastoral initiatives rather than competing with curriculum time. For sustainability, a train-the-trainer model could develop internal capacity while maintaining quality assurance through external supervision. Data from this evaluation can guide such scaling by identifying feasible group sizes, session length and materials adaptable to different literacy and language levels. Future research directions A rigorous next-phase study should employ a quasi-experimental or stepped-wedge design across multiple schools to test the causal validity of observed mechanisms. Outcome measurement should broaden to include teacher-rated behavioural scales, attendance records and disciplinary data, alongside pupil self-reports. Fidelity monitoring, facilitator competence checklists and contextual audits will allow multilevel modelling of variation. Longitudinal follow-up over at least one academic term is needed to detect “sleeper” effects and potential fade-out, as documented in broader SEL literature. Given that the way that pupils are supported through self-discovery and introspection is crucial so that it remains psychologically safe is important, future studies could look at whether a universal school approach is more inclusive. Mixed-methods integration should continue, aligning quantitative trajectories with qualitative narratives through joint displays to refine CMO configurations, whilst also looking to investigate cultural appropriateness of the D&D in different groups. Finally, cost-effectiveness and equity analyses are essential to ensure scalability within resource-constrained local authorities. Conclusion Young Dragons demonstrates that tabletop role-playing (TTRPG), narrative-based interventions can be delivered feasibly and acceptably within UK state schools serving pupils at risk of exclusion. Although statistically significant group-level changes in self-reported wellbeing were not detected, mixed-methods integration revealed mechanism-consistent improvements for many participants, particularly in self-management, cooperation, confidence and peer relationships, when delivery conditions were supportive. Outcomes were contingent on context, including facilitator skill, group stability and environmental predictability, underscoring the importance of implementation quality in creative, school-based mental-health interventions. Consistent with staff narratives of calmer behaviour and fewer behavioural escalations, exploratory analysis of routine school data showed a significant reduction in suspensions and a modest, non-significant increase in attendance over the intervention period, suggesting potential indirect effects on behavioural stability even within a short timeframe. While these findings should be interpreted cautiously, they strengthen the plausibility that narrative, co-regulated play may influence downstream educational outcomes through improved emotional regulation and group functioning. Taken together, this pilot provides a robust feasibility and mechanism-mapping foundation for a next-phase evaluation. Future studies should employ controlled or stepped-wedge designs, incorporate longer follow-up and link pupil-reported outcomes to administrative indicators such as attendance, behaviour and exclusion. With appropriate investment in facilitator training and delivery stability, TTRPG-based interventions such as Young Dragons may form a scalable component of inclusive, preventive mental-health strategies within contemporary school systems. Abbreviations ARC Applied Research Collaboration CASEL Collaborative for Academic, Social, and Emotional Learning CMO Context–Mechanism–Outcome COREQ Consolidated Criteria for Reporting Qualitative Research D&D Dungeons & Dragons EHCP Education, Health and Care Plan EAL English as an Additional Language FSM Free School Meals GRAMMS Good Reporting of A Mixed Methods Study ICREC Imperial College Research Ethics Committee LSA Learning Support Assistant NIHR National Institute for Health and Care Research PRU Pupil Referral Unit RBKC Royal Borough of Kensington and Chelsea SEL Social and Emotional Learning SEND Special Educational Needs and Disabilities SEMH Social, Emotional and Mental Health STROBE Strengthening the Reporting of Observational Studies in Epidemiology TIDieR Template for Intervention Description and Replication TTRPG Tabletop Role–Playing Game WCC Westminster City Council Declarations Ethics approval and consent to participate The study was approved by the Imperial College Research Ethics Committee (ICREC) (reference number ICREC #7802918). Adult participants provided written informed consent prior to participation. For pupil surveys conducted in schools, governance procedures were agreed with headteachers, and instruments were age-appropriate, brief, and administered in class settings with staff support. Anonymity was protected through the use of pseudonymous identifiers, and direct identifiers were removed from analytic datasets. Safeguarding procedures were followed throughout, and no adverse events were reported. Consent for publication Not applicable. Competing Interests G.H. and D.C. are directors of Mythic Minds CIC and were involved in the design and delivery of the Young Dragons intervention. All other authors declare that they have no competing interests. Twitter / X @austenelosta @ImeprialSCARU Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Austen El-Osta and Cornelia Junghans Minton are supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) Northwest London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Author Contribution A.EO and C.J conceptualized the study. A.EO and Y.L conducted the literature review. A.A supported the development of the ethic submission pack. All authors (A.EO, S.A, Y.L, A.A, R.L, S.N, E.S, G.H, D.C, and C.JM supported the development of the data collection instruments. SA. conducted the quantitative data analysis. Y.L conducted interviews and contextual analysis with support from A.EO. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work. AE.O is the guarantor. Acknowledgement The authors wish to acknowledge the support of all staff in participating schools and the parents of the pupils who participated in the intervention. Data Availability The datasets generated and/or analysed during the current study are not publicly available due to ethical and governance restrictions. The study involves minors in school settings, and the quantitative survey data, qualitative interview transcripts, and routine school records contain information that could potentially enable participant or school identification if shared openly. Data access is therefore restricted under the terms of approval granted by the Imperial College Research Ethics Committee and data-sharing agreements with participating schools and local authorities. De-identified and aggregated data supporting the findings of this study may be made available from the corresponding author on reasonable request, subject to review of the request, approval by the relevant data controllers, and completion of appropriate data-sharing agreements. The survey instrument used in the study is provided as **Supplementary File 1.** References Parker C, Ford T. Editorial Perspective: School exclusion is a mental health issue. J Child Psychol Psychiatry. 2013;54(12). Toth K, Cross L, Golden S, Ford T. From a child who IS a problem to a child who HAS a problem: fixed period school exclusions and mental health outcomes from routine outcome monitoring among children and young people attending school counselling. Child Adolesc Mental Health. 2023;28(2):277–86. Weale S. Half of pupils expelled from school have mental health issue, study finds. Guardian Newsp. 2017. Sanders J, Liebenberg L, Munford R. 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Atherton G, Hathaway R, Visuri I, Cross L. A critical hit: Dungeons and Dragons as a buff for autistic people. Autism. 2025;29(2):382–94. Cullinan M, Genova J. Gaming the systems: a component analysis framework for the classroom use of RPGs. Int J Role-Playing. 2023(13):7–17. Stubbs R, Sorensen N. Tabletop Role-Playing Games and Social and Emotional Learning in School Settings. Social Emotional Learning: Res Pract Policy. 2025;5:101016. Pitt C, Chen K, Rubin J, Gibson D, Bindman S. How Youth Can Build Social and Emotional Skills with Tabletop Role-Playing Games. 2023. Otani VHO, Novaes RA, Pedron J, Nabhan PC, Rodrigues TM, Chiba R, et al. Framework proposal for Role-Playing Games as mental health intervention: the Critical Skills methodology. Front Psychiatry. 2024;15:1297332. Hartwig EK, Walker E, Stamman J. Roll for Initiative: Using Dungeons and Dragons in Play Therapy. J Creativity Mental Health. 2025;20(1):113–26. Molloy A. Supporting students wellbeing with Dungeons & Dragons 2024 [2025 Jul 20]. Available from: https://thebuglenews.com.au/NewsStory/supporting-students-wellbeing-with-dungeons-dragons/662b605b076e190029c19dcb Watson A, Dungeons, Dragons, Skills D. How Tabletop Role-Playing Games Make SEL and Academics into an Adventure for Students 2023 [cited 2025 Jul 20]. Available from: https://www.nextgenlearning.org/articles/dungeons-dragons-durable-skills-sel-academics Darvasi P. How 'Dungeons & Dragons' Primes Students for Interdisciplinary Learning, Including STEM 2018 [cited 2025 Jul 22]. Available from: https://www.kqed.org/mindshift/51790/how-dungeons-dragons-primes-students-for-interdisciplinary-learning-including-stem?utm_source=chatgpt.com Gagnier K, Okawa A, Jones-Manson S. Designing and implementing social emotional learning programs to promote equity. Designing and Implementing SEL Programs Equity White Paper; 2022. Gee B, Wilson J, Clarke T, Farthing S, Carroll B, Jackson C, et al. Delivering mental health support within schools and colleges–a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents. Child Adolesc Mental Health. 2021;26(1):34–46. Greenberg MT. Evidence for Social and Emotional Learning in Schools. 2023. Fusch P, Fusch GE, Ness LR. Denzin’s Paradigm Shift: Revisiting Triangulation in Qualitative Research. J Social Change. 2018;10(1):19–32. Liu X, Gurung A, Baker RS, Barany A, editors. Understanding the Impact of Observer Effects on Student Affect. International Conference on Quantitative Ethnography; 2024: Springer. Additional Declarations Competing interest reported. G.H. and D.C. are directors of Mythic Minds CIC and were involved in the design and delivery of the Young Dragons intervention. All other authors declare that they have no competing interests. Supplementary Files Supplementarytable1.docx Supplementaryfile2STROBEChecklist.pdf Supplementaryfile3COREQChecklist.pdf Supplementaryfile1Survyeexport.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 23 Feb, 2026 Reviews received at journal 21 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 31 Dec, 2025 Reviewers invited by journal 30 Dec, 2025 Editor assigned by journal 30 Dec, 2025 Editor invited by journal 28 Dec, 2025 Submission checks completed at journal 26 Dec, 2025 First submitted to journal 26 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8357803","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577197143,"identity":"ee5f1a08-0f75-4cfd-80eb-a80badafb497","order_by":0,"name":"Austen El-Osta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIie2RwUoDMRCGJwS2l0iuU5TuK2QRBFHwVeLJa8HLHmSJFHPqA9THEF9gyoB72QeoLIgieO6xIIqJFi+S1mMP+S6TDHzM/AlAJrObCPoug2sXi4LBT9tscqKCoOZrRf5bQbu+blO0k0RQN42+fb25H9dPB3oCYrkCPkwpSIUl6BixP/f9rLtUyCCHU+Cj9FbK8IcnhKjseauAAfYB+DRllKSXJHyD5eM8KJ9WlWHK+ybFkIKgSDQLERRnw1Ao4pTkYhUXJmYZ3nUxy4NVFQt/PDUXyfijdvLyHF5Mj9r2rR9f2bPQ4cWqPqlcypF/z8Jt+ciEnslkMplfvgAtBVO5eaETNQAAAABJRU5ErkJggg==","orcid":"","institution":"Imperial College London School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Austen","middleName":"","lastName":"El-Osta","suffix":""},{"id":577197144,"identity":"4f9408b1-c049-4ce2-ad3a-8facbd23e839","order_by":1,"name":"Yiran Li","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Yiran","middleName":"","lastName":"Li","suffix":""},{"id":577197145,"identity":"35ce5b57-9a9d-41fe-8363-4d12b76403fc","order_by":2,"name":"Sami Altalib","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"Altalib","suffix":""},{"id":577197146,"identity":"5c465390-1fc1-4724-862b-6f6b73fd9d19","order_by":3,"name":"Aos Alaa","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Aos","middleName":"","lastName":"Alaa","suffix":""},{"id":577197147,"identity":"d70f4f25-5ea5-4510-a9b3-f4f405b2001b","order_by":4,"name":"Rebecca Linsley","email":"","orcid":"","institution":"Royal Borough of Kensington and Chelsea","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Linsley","suffix":""},{"id":577197148,"identity":"334f1ce5-a336-4654-9f27-69285fdba75b","order_by":5,"name":"Sarah Newman","email":"","orcid":"","institution":"Royal Borough of Kensington and Chelsea","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Newman","suffix":""},{"id":577197149,"identity":"c566d8d5-deb7-4a66-aec3-fd5adcb2c68f","order_by":6,"name":"Etiene Steyn","email":"","orcid":"","institution":"Royal Borough of Kensington and Chelsea","correspondingAuthor":false,"prefix":"","firstName":"Etiene","middleName":"","lastName":"Steyn","suffix":""},{"id":577197150,"identity":"d0972ac3-db3f-450a-bad3-c5f3dbf68959","order_by":7,"name":"Gary Harper","email":"","orcid":"","institution":"Mythic Minds CIC","correspondingAuthor":false,"prefix":"","firstName":"Gary","middleName":"","lastName":"Harper","suffix":""},{"id":577197151,"identity":"3542831b-0935-4ca6-be92-1b7dc30fc2ba","order_by":8,"name":"David Coulter","email":"","orcid":"","institution":"Mythic Minds CIC","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Coulter","suffix":""},{"id":577197152,"identity":"a4ca5d07-2e68-4284-8609-6175ed369e47","order_by":9,"name":"Cornelia Junghans Minton","email":"","orcid":"","institution":"Imperial College London","correspondingAuthor":false,"prefix":"","firstName":"Cornelia","middleName":"Junghans","lastName":"Minton","suffix":""}],"badges":[],"createdAt":"2025-12-14 12:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8357803/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8357803/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102425074,"identity":"05d03360-a498-4e00-9e98-4498d970429b","added_by":"auto","created_at":"2026-02-11 14:29:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42348,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA combined bar and line chart with dual y-axes presenting Wilcoxon Signed-Rank Test Results Across Domains. 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The red dashed line marks the p=0.05 threshold.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/20634f11540da648a57c3d0a.png"},{"id":102425069,"identity":"e703cd9f-c353-4f4c-b4cc-7c9dbc9f8cd1","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":156570,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImpact typology\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/0bc5527be0bf328b2c15b7c6.jpeg"},{"id":102425071,"identity":"c9e86f93-861f-4454-aa07-6c2f118a55ad","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":910866,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eColoured matrix of paired participant responses (n=22).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/b28904e56fdf9b4408e565b2.jpeg"},{"id":102745658,"identity":"b199bbd1-329d-4707-9a66-29e890c4aa12","added_by":"auto","created_at":"2026-02-16 08:53:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2709176,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/60923189-c235-4930-8e7b-60f89b2d2f36.pdf"},{"id":102425068,"identity":"51753972-46a7-440c-a637-c02905420c15","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":37563,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/ec7bd130b1dc1ffde733332d.docx"},{"id":102425072,"identity":"3d151f7b-4c27-40f6-9a95-53a39d4f5740","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":113501,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2STROBEChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/3b5db21237cbd23bdcafdc40.pdf"},{"id":102425073,"identity":"e40531fb-19f0-4cb5-a384-13b4ae4fb28a","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":120231,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile3COREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/a7c721a0755d223ca7f711cb.pdf"},{"id":102425070,"identity":"30dd9431-0efc-4735-9cf8-348068d64a20","added_by":"auto","created_at":"2026-02-11 14:29:38","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":233933,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1Survyeexport.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357803/v1/72d03b16adfa4b7363b053ee.pdf"}],"financialInterests":"Competing interest reported. G.H. and D.C. are directors of Mythic Minds CIC and were involved in the design and delivery of the Young Dragons intervention. All other authors declare that they have no competing interests.","formattedTitle":"Imaginative play for inclusion: Evaluating the Young Dragons tabletop role-playing intervention in UK schools","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSchool exclusion is a persistent educational and public health concern in England with consequences that extend across the life course(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Pupils who are suspended or permanently excluded are more likely to experience poor mental health, low attainment and later contact with the criminal justice system(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Recent national figures indicate record levels of suspensions and permanent exclusions, with local patterns that are unequally distributed and concentrated among children already facing adversity, including those with special educational needs and disabilities and those living in poverty(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In Westminster and the Royal Borough of Kensington \u0026amp; Chelsea (RBKC), exclusion rates have at times exceeded London averages and are concentrated in the most deprived wards(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Schools in these boroughs also contend with high proportions of pupils eligible for free school meals, substantial linguistic diversity and rising demand for mental health support(\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The public health and equity implications are clear: exclusion is not simply a disciplinary endpoint, but a marker of unmet social, emotional and mental health (SEMH) need and local education systems require preventative, inclusive responses that can be delivered within the everyday ecology of schools(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAgainst this backdrop, there is growing interest in creative, low stigma, play based interventions that can strengthen social\u0026ndash;emotional learning (SEL) while engaging pupils who may be ambivalent toward conventional support(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Tabletop roleplaying games (TTRPGs), notably Dungeons \u0026amp; Dragons (D\u0026amp;D), have emerged internationally as promising tools for cultivating communication, collaboration, perspective taking and problem-solving(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Yet their application in UK state schools remains rare, the evidence base is thin in formal education settings and, crucially, little is known about how such programmes are experienced and implemented in real classrooms serving diverse, high need cohorts\u003c/p\u003e \u003cp\u003eThe theoretical appeal of TTRPGs for SEL lies in the way structured narrative, rules and collaboration combine to create psychologically safe conditions for social risk taking and identity work(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In D\u0026amp;D, pupils adopt characters, co-create stories, negotiate choices and contend with consequences inside a rule governed, facilitator led environment(\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These mechanics align with the five competencies in the CASEL framework self-awareness, self-management, social awareness, relationship skills and responsible decision making by requiring turn taking, empathic perspective taking, conflict navigation and reflective decision making in a shared enterprise(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The format also supports coregulation: pupils practise sharing the spotlight, reading group norms and making joint plans, while the rules scaffold fairness and predictability(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In short, the game world functions as a \u0026ldquo;safe laboratory\u0026rdquo; where pupils can rehearse different versions of themselves and transfer emerging skills into everyday school life(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlthough therapeutic and community studies have reported improvements in anxiety, self-esteem, social connection and teamwork associated with TTRPG participation, the translation of these gains into mainstream UK schools and the conditions that enable or constrain them remain underexamined(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Teachers\u0026rsquo; perspectives are especially underrepresented despite teachers\u0026rsquo; pivotal role in observing day-to-day behaviours, judging acceptability and brokering practical fit with timetables, staffing and safeguarding routines(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Recent qualitative work embedded in central London schools suggests teachers observe changes across all five CASEL domains when TTRPG programmes are delivered in small, supported groups, but also identifies salient implementation questions: who benefits, under what conditions and how can delivery be sustained at scale without diluting quality\u003c/p\u003e \u003cp\u003eThe Young Dragons pilot was designed to address these questions in real school contexts. Commissioned by the BI Borough Children\u0026rsquo;s Services and delivered with Mythic Minds CIC across ten state schools in Westminster (WCC) and RBKC, the programme targeted pupils aged 9\u0026ndash;16 identified by school staff as at risk of exclusion, socially isolated, or experiencing SEMH difficulties. Delivery consisted of weekly one-hour sessions over six to eight weeks in small, consistent groups of four to six pupils, facilitated by trained \u0026ldquo;storytellers\u0026rdquo; with school staff present in a supervisory or co-facilitative capacity. The core pedagogical logic combined imaginative play, cooperative problem solving and structured reflection, with the intention of building trust, communication, self-regulation and a sense of belonging. In practice, delivery had to accommodate the variability that typifies urban schooling: timetable pressures, room availability, attendance fluctuations, group composition and the need to adapt scenarios to the developmental stage and diversity of each cohort.\u003c/p\u003e \u003cp\u003eThe primary aim of this realist evaluation is to assess the impact of the Young Dragons programme on the emotional wellbeing, social communication and school engagement of pupils aged 9\u0026ndash;16 identified as at risk of exclusion or experiencing SEMH needs. Specifically, the evaluation sought to: (i) explore changes in self-esteem, emotional regulation and perceived school belonging because of programme participation, (ii) gather pupil-reported experiences of loneliness and inclusion before and after the intervention, (iii) identify delivery challenges and contextual factors influencing programme fidelity, engagement and acceptability and (iv) generate recommendations for refinement, scalability and future implementation across similar school settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a convergent mixed methods evaluation with a realist orientation, conducted as pre-post pilot in mainstream, through secondary and alternative provision schools in WCC and RBKC. The design was pragmatic, chosen to test feasibility and acceptability under real delivery constraints, to describe within person change in key social emotional domains and to develop explanatory accounts of how context and mechanisms conditioned outcomes. The mixed methods frame enabled parallel quantitative and qualitative analyses followed by structured integration to build context\u0026ndash;mechanism\u0026ndash;outcome (CMO) propositions. Reporting follows GRAMMS for mixed methods, STROBE for the quantitative observational component, COREQ for the qualitative interviews and RAMESES II for realist logic, with TIDieR informed description of the intervention components.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting, participants and recruitment\u003c/h3\u003e\n\u003cp\u003eThe intervention ran across ten state funded schools spanning primary, secondary, an all through academy and a pupil referral unit. School inclusion reflected the local mix of high deprivation, elevated free school meal eligibility, substantial proportions of pupils using English as an additional language and rising presentations of social, emotional and mental health need. Pupils aged 9\u0026ndash;16 were nominated by special educational needs coordinators, heads of year, or inclusion leads based on observed risk of exclusion, SEMH challenges, social isolation, or disengagement. Exclusion criteria were minimal and limited to acute risk or placement in intensive specialist provision. Groups were kept small (typically 4\u0026ndash;6) and pupils remained with the same peers to support cohesion, trust and narrative continuity. School staff were present during sessions in a supervisory or facilitative role.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eYoung Dragons comprised weekly one-hour sessions of the tabletop roleplaying game Dungeons \u0026amp; Dragons for six to eight weeks, delivered on school premises by trained facilitators from the social enterprise Mythic Minds CIC. Sessions followed a consistent arc of check-in and recap, facilitated narrative play, cooperative problem-solving and guided debrief with explicit links to emotions, group process and transfer to school life. The format leveraged structured rules, turn taking, character perspective taking and collective decision-making to exercise competencies aligned with the CASEL framework (self-awareness, self-management, social awareness, relationship skills, responsible decision making). Scaffolding and scenario complexity were adjusted to age, literacy and group dynamics. Fidelity was supported by facilitator supervision and weekly debriefs, while adaptation to timetable and space constraints preserved ecological fit.\u003c/p\u003e\n\u003ch3\u003eQuantitative measures and data collection\u003c/h3\u003e\n\u003cp\u003ePupil reported outcomes were collected immediately before the first gaming session and after the final session using a bespoke, age-appropriate survey codeveloped with educators and the delivery partner. Items captured emotional wellbeing, self-concept and confidence, emotional regulation (stress, anger control, feeling control), social communication and peer support, loneliness (direct measure) and school engagement (belonging and enjoyment). Response formats used simplified Likert scales and emoji aided anchors to enhance accessibility. Free text questions captured brief reflections. To preserve anonymity while enabling linkage, pupils used pseudonymous \u0026ldquo;hero names\u0026rdquo;; manual reconciliation of minor spelling variants was undertaken to maximise match accuracy. Surveys were administered in class time as paper or online forms with adult support when required. Data quality screening excluded test entries, nonconsent and irreconcilable records. The survey was disseminated on the Qualtrics XLM platform. The electronic survey is included in \u003cb\u003eSupplementary File 1\u003c/b\u003e.\u003c/p\u003e\n\u003ch3\u003eQuantitative analysis\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics using frequencies and percentages summarised response distributions at each timepoint across domains for all available cases. Pre\u0026ndash;post within person change for matched pairs was estimated using the Wilcoxon signed rank test for ordinal outcomes, reporting p-values and signed Z statistics. Statistical significance was set at 0.05. Data was analysed using STATA 18 STATA, version 18 (StataCorp LP, College Station, TX, USA).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative design, sampling and data collection\u003c/h2\u003e \u003cp\u003eThe qualitative strand adopted an interpretivist approach to capture the experiences of those closest to delivery, focusing on teacher perspectives on pupil change, implementation enablers and barriers and prospects for sustainability. Semi structured interviews were conducted with nine participants comprising school-based staff and facilitators; interviews lasted approximately 20\u0026ndash;45 minutes, were held via Microsoft Teams and followed a topic guide covering general impressions, perceived impact across SEL domains, practicalities of delivery and future relevance. In parallel, nonparticipant observation of three multiagency steering group meetings provided contextual insight into coordination, adaptive strategies and process learning across sites. With consent, interviews were audio recorded for verbatim transcription; identifiable details were pseudonymised. Field notes from observations were recorded systematically; to reduce reactivity, direct session observation was avoided when it inhibited pupil spontaneity, with the team privileging post session debriefs for richer, less intrusive insight.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative analysis\u003c/h3\u003e\n\u003cp\u003eTranscripts were imported into NVivo 14 and analysed using thematic analysis following Braun and Clarke\u0026rsquo;s six phase procedure. Coding was inductive and data driven in the first cycle to preserve participants\u0026rsquo; language and local meaning, with iterative development of candidate themes capturing pupil level changes, group dynamics, facilitation and organisational conditions. In a second analytic pass, themes were mapped onto the CASEL framework to identify which competencies were most salient and to test alignment between reported changes and the programme\u0026rsquo;s theory of change. Observational notes were not formally coded but were used for triangulation and to refine theme boundaries and interpretations. Analytic memos recorded decisions, reflexive considerations and deviant cases. COREQ informed documentation of researcher roles, data saturation rationale and procedures to enhance trustworthiness.\u003c/p\u003e\n\u003ch3\u003eMixed methods integration and realist synthesis\u003c/h3\u003e\n\u003cp\u003eIntegration used a convergent design in which quantitative and qualitative strands were analysed independently and then brought together through joint displays and realist pattern matching. Joint displays aligned pre\u0026ndash;post distributions and matched pair change patterns by domain with illustrative teacher quotations and facilitation narratives, enabling inspection of convergence, complementarity, or divergence. A realist heuristic guided the development of CMO propositions. For example, small, stable groups led by skilled facilitators (context) appeared to trigger coregulated play, perspective taking and collaborative problem solving (mechanisms), which for pupils with high baseline dysregulation manifested as improved anger control, teamwork and confidence (outcomes); conversely, timetable pressure, space changes, or unfamiliar adults (context) appeared to blunt engagement and attenuate gains in school belonging (outcome). Integration outputs were used to refine practical guidance and to specify testable hypotheses for future controlled or stepped wedge evaluations.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReporting standards and methodological frameworks\u003c/h2\u003e \u003cp\u003eThis study was designed and reported in accordance with established reporting and methodological guidance appropriate to each component of the evaluation. The quantitative observational component followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The qualitative interview component was reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Integration of quantitative and qualitative findings followed the Good Reporting of A Mixed Methods Study (GRAMMS) framework.\u003c/p\u003e \u003cp\u003eGiven the programme\u0026rsquo;s theory-driven, explanatory focus, a realist orientation was adopted to explore how outcomes varied by context. Development and reporting of context\u0026ndash;mechanism\u0026ndash;outcome (CMO) configurations were informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES II) guidance. Description of the Young Dragons intervention and its delivery was structured using the Template for Intervention Description and Replication (TIDieR) checklist to support transparency and replicability.\u003c/p\u003e \u003cp\u003eCompleted STROBE and COREQ checklists are provided as supplementary materials (\u003cb\u003esupplementary files 2 and 3\u003c/b\u003e respectively)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eParticipants and data completeness.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAcross ten schools, 86 pupil surveys were collected between May-July 2025. After data quality checks (removal of test entries, non-consent and irreconcilable identifiers), 50 baseline and 36 post-intervention surveys were retained. Of these, 22 pupils could be matched pre-post using pseudonymous \u0026ldquo;hero names.\u0026rdquo; Interview data comprised nine semi-structured interviews with school staff and facilitators, alongside non‑participant observations from three multi‑agency steering group meetings. No adverse events were reported. The Main survey findings are illustrated in \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eChanges in Students\u0026rsquo; Wellbeing and Self-Perception\u003c/h2\u003e \u003cp\u003eDistributions at the group level were broadly stable but showed visible polarisation on several items. For overall mood (\u0026ldquo;How is everything going?\u0026rdquo;), the most positive category remained high (46.0% at baseline versus 50.0% post), while the most negative category emerged at follow-up (0.0% to 13.9%). School engagement showed a similar bifurcation: \u0026ldquo;\u0026#128522;\u0026#128077;\u0026#128077;\u0026rdquo; was 32.0% at baseline and 33.3% post, but \u0026ldquo;☹ฏ\u0026#128078;\u0026#128078;\u0026rdquo; increased from 2.0% to 16.7%. Self-concept showed mixed movement: endorsement of \u0026ldquo;I have a number of good qualities\u0026rdquo; increased in the \u0026ldquo;agree/strongly agree\u0026rdquo; range (66.0% to 69.5%) and \u0026ldquo;unsure\u0026rdquo; declined (22.0% to 13.9%), yet \u0026ldquo;I feel good about myself\u0026rdquo; saw \u0026ldquo;strongly disagree\u0026rdquo; rise (6.0% to 16.7%). For emotional regulation, anger control shifted positively (\u0026ldquo;true\u0026rdquo; 14.0% to 27.8%, \u0026ldquo;very not true\u0026rdquo; 24.0% to 11.1%), whereas stress coping remained challenging, with high \u0026ldquo;unsure\u0026rdquo; at both timepoints. Loneliness \u0026ldquo;often/always\u0026rdquo; rose from 2.0% to 8.3%. School belonging remained mostly moderate to high, but \u0026ldquo;not at all true\u0026rdquo; increased (12.2% to 19.4\u003cb\u003e%\u003c/b\u003e); \u003cb\u003eSupplementary Table\u0026nbsp;1.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative outcomes\u003c/h2\u003e \u003cp\u003eMatched-pair analysis of 22 pupils showed no statistically significant changes across any primary outcome items (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, directionally, several domains suggested small improvements after the intervention. General self-assessment (\u0026ldquo;How are you doing?\u0026rdquo;) showed the largest positive shift (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.777, p\u0026thinsp;=\u0026thinsp;0.107), indicating higher post-intervention ratings. Measures of competence (\u0026ldquo;I am able to do things as well as most other people\u0026rdquo;) and personal qualities also trended upward (Z\u0026thinsp;=\u0026thinsp;1.635 and 1.448, respectively). Indicators related to mood, school belonging, and social relationships remained broadly positive and stable from baseline to follow-up. Family relationships continued to score highly, with no deterioration observed. Measures of emotional control and stress coping showed small, non-significant fluctuations, suggesting overall stability rather than decline. While statistical significance was not achieved, descriptive trends indicated modest improvements in self-perceived competence, self-assessment, and peer support following the intervention. The pattern is consistent with feasibility-focused inference and heterogeneous trajectories rather than uniform group-level change.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMatched pair Wilcoxon signed rank tests for primary outcome items (n\u0026thinsp;=\u0026thinsp;22). All p\u0026thinsp;\u0026gt;\u0026thinsp;0.10; negative Z indicates higher post scores on items framed positively and vice versa as reported in the source table\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain / Item\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral mood \u0026ldquo;How is everything going?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool engagement \u0026ldquo;How are you doing at school?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily relationships \u0026ldquo;How are things in your family?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral self-assessment \u0026ldquo;How are you doing?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;1.777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with self \u0026ldquo;I am satisfied with myself\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal qualities \u0026ldquo;I have a number of good qualities\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetence \u0026ldquo;I am able to do things as well as most other people\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeling good about oneself \u0026ldquo;I feel good about myself\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl over feelings \u0026ldquo;I find it hard to control my feelings\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress-coping \u0026ldquo;I\u0026rsquo;m able to deal with stress\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnger control \u0026ldquo;I can control my anger when I want to\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGetting along \u0026ldquo;I get along with people around me\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeing liked \u0026ldquo;People like to spend time with me\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;1.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFriend support \u0026ldquo;I feel supported by my friends\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.663\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFriends\u0026rsquo; care \u0026ldquo;My friends care about me when times are hard\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurn-taking \u0026ldquo;I take turns when playing games with others\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoneliness \u0026ldquo;How often do you feel lonely?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool belonging \u0026ldquo;I feel like I belong at my school\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;1.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnjoyment of school \u0026ldquo;I enjoy coming to school\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.551\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResponder heterogeneity\u003c/h2\u003e \u003cp\u003eAggregated counts show concurrent improvements and deteriorations within the same cohort, highlighting nonuniform response (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For example, for overall mood, 6 pupils improved, 12 were unchanged and 4 worsened; for school engagement 5 improved and 8 worsened; for competence self-appraisal 11 improved and 5 worsened; for anger control 7 improved and 8 worsened. For items where \u0026ldquo;higher\u0026rdquo; reflects more difficulty (\u0026ldquo;hard to control my feelings\u0026rdquo;; loneliness), worsened counts capture movement toward greater difficulty. These distributions support a three-way typology suggested by the descriptive data: pupils who improved on several domains, pupils who remained broadly stable and pupils who shifted toward more negative responses postintervention. This structure is not visible in central tendency but is evident in category movement and individual trajectories.\u003c/p\u003e \u003cp\u003eKey demographic data from the 10 participating schools is shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below. Across 30 matched pupils with attendance and suspension data, mean attendance increased from 90.6% to 92.7%, although this did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.069). Importantly, mean suspensions declined significantly, from 0.7 pre-intervention to 0.0 post-intervention (p\u0026thinsp;=\u0026thinsp;0.022). From the data, a three-way typology of impact can be inferred (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The presence of all three groups is a hallmark of early-stage, creative mental health programmes delivered in real-world, high-need school contexts. A confusion matrix (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) provides a visual synthesis of paired participant feedback across key domains of the Young Dragons intervention. The matrix provides a visual synthesis of paired participant feedback across key domains of the Young Dragons intervention. Colours denote the nature of responses (positive, neutral, or negative), enabling at-a-glance comparison across participants and domains. Green denotes a Positive response (clear evidence of improvement or benefit), Amber denotes a neutral/mixed response (limited change or varied perspectives), Red denotes a negative response (no improvement or reported concern).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePaired response change counts by item (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem (paired analysis)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWorsened\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow is everything going?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow are you doing at school?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow are things in your family?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow are you doing?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am satisfied with myself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have a number of good qualities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am able to do things as well as most other people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI feel good about myself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI find it hard to control my feelings*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u0026rsquo;m able to deal with stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI can control my anger when I want to\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI get along with people around me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeople like to spend time with me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI feel supported by my friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMy friends care about me when times are hard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI take turns when playing games with others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you feel lonely?*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI feel like I belong at my school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI enjoy coming to school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e127\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e200\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e91\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Higher post values on these items indicate greater difficulty (worse outcome).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipating school demographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchool Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% FSM Eligible\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% SEND Support\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% SEN Education, Health \u0026amp; Care Plan (EHCP)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% Pupils 1st language not EN (2023/24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Suspension Rate (2023/24)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eRBKC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSt Francis of Assisi RC primary school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eServite RC primary school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAvondale Park primary school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHolland Park School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eKensington Aldridge Academy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e44.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eWCC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGateway Primary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e89.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQueen\u0026rsquo;s Park Primary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eKing Solomon Academy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWestminster Academy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e56.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSt Marylebone CofE School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eQualitative outcomes\u003c/h2\u003e \u003cp\u003eThis study explored the perceptions of educators, programme staff and a parent involved in the D\u0026amp;D pilot. A total of 7 interviews were conducted between 11 and 21 July. Participant characteristics are shown in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant role\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther notes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommissioners \u0026amp; Programme Leads\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncluded commissioners, public health, programme managers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMythic Minds CiC Intervention leads\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeep overview of delivery of intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePastoral support worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestminster Academy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubstituting for Y7 colleague, direct observations\u0026thinsp;+\u0026thinsp;staff feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning Support Assistant (LSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSt Marylebone High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttended all but one session, participant-observer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent of pupil / School admin staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvondale Park Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParent of pupil with SEND; also worked in school office\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool learning mentor (teacher)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvondale Park Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccompanied children in the games sessions, witnessed increase in turn-taking, better collaboration as the imitative progressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadteacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSt Francis of Assisi Primary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDid not attend sessions but spoke to children before and afterwards and engaged with the storyteller after the sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadteacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQueen\u0026rsquo;s Park Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttended sessions and observed increase in confidence and turn taking. Being able to advocate for themselves.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-Head teacher with responsibility for children with additional needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGateway Academy (primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccompanied children, witnessed improvement in turn taking, improved social interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFive overarching categories emerged, capturing socio-emotional gains, confidence \u0026amp; self-expression, social connection, creativity and implementation factors. These qualitative findings help contextualise the quantitative results, highlighting how the programme influenced pupils and the conditions that supported or constrained its delivery. Several themes emerged from the interviews which could be grouped into five categories (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of qualitative themes from Young Dragons evaluation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEngagement \u0026amp; initial perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcitement \u0026amp; curiosity about D\u0026amp;D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStaff curiosity; novelty of approach; relevance to pupils already interested in D\u0026amp;D\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive reception \u0026amp; buy-in\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly enthusiasm from pupils; rapid engagement; willingness to try\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParental perceptions \u0026amp; consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFace-to-face \u0026amp; email communication; initial scepticism vs later support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocial interaction \u0026amp; peer relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntra-group dynamics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBonding across classes; teasing \u0026amp; camaraderie; handling interpersonal conflict\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaboration \u0026amp; teamwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTurn-taking; listening skills; problem-solving together\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-cultural exchange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning from culturally diverse peers; inclusive participation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePersonal development \u0026amp; behavioural change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCalmer behaviour; self-control; fewer behavioural incidents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproved lesson readiness; reduced exclusions; better instruction-following\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfidence \u0026amp; self-expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncreased social participation; role-play enabling safe expression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerspective shifts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChanges in perception of authority figures; feeling understood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFacilitator \u0026amp; programme design factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkilled facilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnthusiastic, informal, and structured leadership\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructure \u0026amp; pacing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBreaking tasks into steps; clear expectations; safe environment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptimal conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAppropriate age groups; session length; number of participants\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOutcomes, sustainability \u0026amp; unintended effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive spillover\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproved relationships outside the game; parental observations of home behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnintended outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthened adult\u0026ndash;student rapport; peer fallouts unrelated to programme\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSustainability \u0026amp; scalability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeed for longer interventions; expansion to more pupils; integration into wider wellbeing strategies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTeacher and facilitator accounts converged on strong engagement, small group safety and gains in self-management, teamwork, confidence and social connection for many participants, with variability linked to facilitation, group composition and scheduling. Staff described shifts from competition to collaboration (\u0026ldquo;\u003cem\u003e\u0026lsquo;I want to go first\u0026rsquo;\u0026hellip; now they understand they have to take turns, they have to work as a team\u0026rdquo;\u003c/em\u003e), improved emotional regulation (\u0026ldquo;being able to stop, understand and follow instructions\u0026rdquo;) and increased confidence and voice among previously quiet pupils (\u0026ldquo;\u003cem\u003ehe\u0026rsquo;s very vocal\u0026hellip; speaks with a louder voice and his head held up high\u0026rdquo;).\u003c/em\u003e A parent who was also a member of staff in a participating school noted spillover beyond sessions (\u0026ldquo;\u003cem\u003ehe was quite calm\u0026hellip; he listened and engaged\u0026rdquo;; \u0026ldquo;even at home he was more compliant\u0026rdquo;).\u003c/em\u003e The D\u0026amp;D format was viewed as therapeutic without stigma, combining structure and imaginative freedom in a psychologically safe space, though early hesitancy, selection stigma and timetable/resource constraints were reported. Facilitator skill was repeatedly identified as critical to holding boundaries, pacing narratives and adapting challenges to developmental level.\u003c/p\u003e \u003cp\u003eMapping of interview material to CASEL competencies indicated the most salient domains were self-management (eight instances) and relationship skills (seven), followed by responsible decision making (four), with fewer explicit references to self-awareness and social awareness (two each). This profile mirrors the quantitative signals in anger control, peer support and cooperation. Stakeholders expressed a desire to continue and expand provision, paired with recognition that sustainability will require predictable scheduling, dedicated space and capacity building for trained delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMixed methods integration\u003c/h2\u003e \u003cp\u003eThe integrated joint displays aligned three recurrent quantitative and qualitative patterns. First, improved anger control and cooperation for a substantial subgroup cooccurred with teacher observed coregulation and turn taking in small, stable groups led by skilled facilitators. Second, stable or strengthened belonging and enjoyment for many pupils coexisted with a minority shift toward low categories; interviews attributed the divergence to timetable pressure, unfamiliar adults and space changes that blunted engagement. Third, modest gains in competence self-appraisal and \u0026ldquo;good qualities\u0026rdquo; mapped to vignettes of confidence and leadership emergence, especially among previously withdrawn pupils, while the small rise in strong negative self-appraisals was interpreted as increased self-reflection for a few. These patterns support provisional context\u0026ndash;mechanism\u0026ndash;outcome propositions to be tested in a longer follow up: small, consistent groups and skilled facilitation (context) trigger coregulated play and perspective taking (mechanism), producing improved self-management and teamwork (outcome); delivery instability (context) dampens the same mechanisms, attenuating belonging and engagement (outcome).\u003c/p\u003e \u003cp\u003eA systematic review of the transcripts identified 8 instances of self-management, 7 of relationship skills, 4 of responsible decision-making, 2 of social awareness and 2 of self-awareness. These counts represent explicit, observable behaviours or reflections aligned with each CASEL competency and provide insight into the areas where the programme\u0026rsquo;s impact was most evident. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents a representative quote from each CASEL domain including the relative frequency of each competency observed in the dataset.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuote matrix and frequency distribution (CASEL framework)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ef\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSource\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecognizing emotions and strengths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne student said that they believed that \u0026ldquo;my self-management has improved, and I can see it\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003eWhat they lacked was being able to regulate their emotions, being able to stop, understand and follow instructions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWestminster Academy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReflecting on self through role-play\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThey said, \u0026ldquo;It was the highlight of my week\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003eIt was an opportunity for them to express themselves in a safe environment through a character\u0026hellip; and learn how that impacts other people.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLearning support assistant \u0026sbquo; St Marylebone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSelf-management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproved emotional regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIn the very beginning they would argue\u0026sbquo; but now they understand they have to take turns, they have to work as a team using their confidence in wanting to work together rather than against each other.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWestminster Academy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransfer of regulation skills to home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEven at home\u0026sbquo; they are more compliant and better at understanding instructions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParent feedback via Westminster Academy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSocial awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmpathy and cross-group interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHe was more social in that group\u0026hellip; he spoke to children from the other class. He was excited about it.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParent at St Francis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAppreciating different perspectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIt captured their imagination\u0026sbquo;. It allowed expression and imagination to flourish.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLearning support assistant, St Marylebone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRelationship skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproved peer-staff relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne student I really speak to me at all, Now she waves, engages in conversation, is friendly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLearning support assistant, St Marylebone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive facilitation and group cohesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRupert was very good. He was skilled at being friends with the girls, holding the game and making the experience enjoyable for everybody.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLearning support assistant Marylebone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResponsible decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaking constructive choices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSometimes they might use that confidence to say what\u0026rsquo;s on their mind happen, allowing them to step into the right places.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWestminster Academy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCollaborative problem-solving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThey had to fi figure out how to get back from the island. Him and his friend done it together.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParent at St Francis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal findings\u003c/h2\u003e \u003cp\u003eThis convergent realist mixed-methods pilot evaluated the Young Dragons tabletop role-playing intervention for pupils at risk of exclusion across ten state schools in WCC and RBKC. Quantitative results did not show any statistically significant average pre-post changes across matched pairs, yet distributions showed simultaneous improvement and deterioration in emotional wellbeing, self-concept, anger control and school belonging. In addition to pupil-reported outcomes, routine school records provided a complementary behavioural signal. Across 30 matched pupils with available attendance and suspension data, mean attendance increased from 90.6% to 92.7% over the intervention period, although this change did not reach conventional statistical significance (p\u0026thinsp;=\u0026thinsp;0.069). More notably, mean suspensions declined significantly from 0.7 pre-intervention to 0.0 post-intervention (p\u0026thinsp;=\u0026thinsp;0.022). While these findings should be interpreted cautiously given the small sample and short follow-up, they are directionally consistent with staff accounts describing calmer behaviour, improved emotional regulation and fewer behavioural escalations during and after sessions. Within a realist interpretation, these patterns suggest that the programme may exert indirect effects on behavioural stability through mechanisms of co-regulation, turn-taking and increased psychological safety, even over a brief delivery window. This quantitative signal aligns with school narratives describing calmer behaviour, improved regulation and fewer behavioural escalations. Qualitative accounts described strong engagement, psychological safety and visible gains in self-management, teamwork and peer connection for many participants, alongside implementation challenges related to scheduling, space and facilitator stability. Integration of both strands supports a mechanism-based interpretation- that outcomes were conditioned by context and facilitation rather than uniform programme effects. Collectively, these findings strengthen the case that Young Dragons may indirectly support attendance and behavioural stability even within a short timeframe\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation of quantitative and qualitative results\u003c/h2\u003e \u003cp\u003eThe absence of statistically significant mean change reflects the design and sample rather than lack of impact. With only 22 matched pairs and a six-to-eight-week exposure window, the analysis was under-powered for conventional significance testing. However, the directionality of change and category shifts point to a phenomenon of polarisation, typical in developmental and psychosocial pilots where some pupils thrive while others show transient discomfort or disengagement.\u003c/p\u003e \u003cp\u003eTeachers and facilitators described the same heterogeneity: pupils who entered sessions withdrawn often became more expressive and cooperative, while a smaller subset appeared unsettled by introspection or the unstructured nature of imaginative play. The programme\u0026rsquo;s mechanisms narrative immersion, cooperative rule-based interaction and structured reflection appear to benefit pupils ready for social learning, while those with unresolved distress or unstable attendance may require longer exposure and additional containment to avoid reactive stress. This nuanced picture illustrates why early-stage, creative interventions should be interpreted through a realist rather than positivist lens.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMechanisms of change\u003c/h2\u003e \u003cp\u003eFindings align closely with the intervention\u0026rsquo;s theory of change and with SEL scholarship. The Young Dragons format created a predictable, rule-governed micro-community that exercised the CASEL competencies: (i) Self-management emerged through anger control, turn-taking and behavioural regulation; (ii) Relationship skills through collaboration and empathy in shared quests, (iii) Self-awareness through character creation and \u0026ldquo;safe self-projection\u0026rdquo; and (iv) Responsible decision-making through simulated moral and strategic dilemmas.\u003c/p\u003e \u003cp\u003eTeachers linked positive behavioural changes to these mechanisms, noting calmer classroom conduct and renewed confidence among participants. Where the setting was disrupted by room changes, timetable clashes, or untrained facilitators the same mechanisms were blunted and pupils\u0026rsquo; sense of belonging declined. In realist terms, the context (stable group, skilled facilitator, consistent space) triggered mechanisms of co-regulation and perspective-taking that yielded positive outcomes, while adverse contexts interrupted these chains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparison with existing evidence\u003c/h2\u003e \u003cp\u003eThe findings corroborate international literature demonstrating TTRPGs can enhance social confidence, empathy and teamwork through narrative collaboration(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Studies in therapeutic and community settings have reported reduced anxiety and improved self-esteem after Dungeons \u0026amp; Dragons interventions(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similar school-based experiments in Australia and North America show increases in communication skills and prosocial behaviour(\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The present study extends this evidence into the UK state-school context and adds teachers\u0026rsquo; perspectives, which are scarce but essential for implementation science(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnlike earlier research in after-school or clinical environments, this pilot occurred during standard timetable hours, within high-need urban schools characterised by linguistic diversity and resource constraints. That the intervention was both feasible and welcomed by staff indicates that TTRPG-based SEL programmes can translate beyond voluntary clubs into mainstream inclusion policy, provided their delivery is carefully scaffolded.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eInfluence of local context\u003c/h2\u003e \u003cp\u003eWCC and RBKC present unique conditions for evaluating creative, low-stigma mental-health interventions. Despite their overall affluence, both boroughs exhibit high deprivation pockets, elevated free-school-meal eligibility and one of the highest proportions of pupils with English as an additional language in England. Demand for child mental-health services far exceeds capacity. In this environment, imaginative group interventions can offer accessible early support that complements overstretched specialist services.\u003c/p\u003e \u003cp\u003eThe pilot\u0026rsquo;s success in operating across ten schools demonstrates adaptability to these complex systems. However, logistical friction competing timetable priorities, room availability and fluctuating staff support significantly influenced outcomes. Such contextual realities reinforce that scalability depends not only on curriculum fit but also on administrative and infrastructural readiness.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImplementation lessons\u003c/h2\u003e \u003cp\u003eThe evaluation identifies several actionable levers for practitioners and commissioners. In terms of facilitation quality, teacher narratives converge on the importance of highly skilled facilitators able to manage behaviour, maintain narrative coherence and balance therapeutic empathy with classroom discipline(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Group size and consistency was also important as \u003cb\u003ec\u003c/b\u003eohorts of four to six pupils were optimal for engagement and safety. Larger or unstable groups risked dominance by a few voices and loss of trust. Environmental stability is deemed crucial as \u003cb\u003ec\u003c/b\u003eonsistent time slots and dedicated rooms created predictability essential for pupils with SEMH needs(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Stigma-free recruitment was essential, including \u003cb\u003el\u003c/b\u003eabelling sessions as \u0026ldquo;creative storytelling\u0026rdquo; or \u0026ldquo;leadership\u0026rdquo; rather than \u0026ldquo;intervention\u0026rdquo; improved acceptability among families and pupils. Finaly, bridging to the classroom using structured reflection linking in-game behaviour to real-life contexts could strengthen skill transfer and allow teachers to reinforce lessons learned(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). These levers correspond to known fidelity drivers in SEL implementation research and provide a roadmap for integrating TTRPG-based learning within inclusive-education strategies(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s strengths lie in its ecological validity and methodological integration. It was embedded in routine school practice, spanned multiple educational phases and engaged high-need populations under real delivery conditions. The convergent mixed-methods design allowed quantitative heterogeneity to be interpreted through qualitative mechanism analysis, preventing premature conclusions from under-powered statistical testing. The realist orientation generated explanatory hypotheses rather than binary verdicts and triangulation between teacher interviews, facilitator reflections and steering-group observations increased trustworthiness(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Finally, the study demonstrated that brief, child-friendly surveys can be administered feasibly in classroom settings to capture SEL-relevant constructs.\u003c/p\u003e \u003cp\u003eThe principal limitation of this study is the single-arm pre\u0026ndash;post structure precludes causal inference; regression to the mean and concurrent school factors cannot be ruled out. The small matched-pair sample and attrition between timepoints reduce statistical power. Survey responses may reflect transient mood or social desirability, especially in multilingual cohorts with varying literacy. Ordinal scales compress variance and may not capture nuanced change. Exposure of only six to eight weeks may be insufficient for sustained social-emotional development and long-term outcomes remain unknown(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the qualitative component, the necessity to avoid intrusive observation reduced opportunities for behavioural coding and inclusion of two facilitators among interviewees may have introduced positive bias(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Nevertheless, reflexive documentation and triangulation mitigated these risks. Overall, the evaluation should be viewed as a feasibility and mechanism study rather than a definitive test of effectiveness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eImplications for theory\u003c/h2\u003e \u003cp\u003eThe study adds to the theoretical understanding of how narrative play facilitates social-emotional learning. It supports models of co-regulated learning where structured fantasy environments allow pupils to practise emotional regulation and perspective-taking without real-world penalty. The observation of \u0026ldquo;polarisation\u0026rdquo; parallels developmental models in which increased self-reflection temporarily heightens distress before consolidation an effect reported in expressive and drama-based therapies. The realist CMO mapping derived here can inform refinement of programme theory: (i) Context: small, stable groups; skilled facilitation; consistent environment, (ii) Mechanism: co-regulated play, narrative identity exploration, perspective-taking and (iii) Outcome: improved self-management, confidence, teamwork and belonging. Conversely, when contextual supports weaken, mechanisms misfire, producing disengagement or transient distress. These propositions generate empirically testable hypotheses for the next stage of research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePolicy and practice implications\u003c/h2\u003e \u003cp\u003eAt policy level, Young Dragons aligns with the UK Government\u0026rsquo;s inclusive-education and mental-health-in-schools agendas. It operationalises prevention within the school day and demonstrates how public-health principles early intervention, low stigma and co-production can be applied through creative pedagogy. Commissioners seeking to reduce exclusions should consider TTRPG-based interventions as part of multi-tiered support systems, ensuring that procurement specifies facilitator qualifications, safeguarding standards and fidelity monitoring.\u003c/p\u003e \u003cp\u003eFor schools, embedding requires structural support: ring-fenced time, leadership buy-in and trained internal champions. Teachers involved in this study viewed the programme as complementing existing pastoral initiatives rather than competing with curriculum time. For sustainability, a train-the-trainer model could develop internal capacity while maintaining quality assurance through external supervision. Data from this evaluation can guide such scaling by identifying feasible group sizes, session length and materials adaptable to different literacy and language levels.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eFuture research directions\u003c/h2\u003e \u003cp\u003eA rigorous next-phase study should employ a quasi-experimental or stepped-wedge design across multiple schools to test the causal validity of observed mechanisms. Outcome measurement should broaden to include teacher-rated behavioural scales, attendance records and disciplinary data, alongside pupil self-reports. Fidelity monitoring, facilitator competence checklists and contextual audits will allow multilevel modelling of variation. Longitudinal follow-up over at least one academic term is needed to detect \u0026ldquo;sleeper\u0026rdquo; effects and potential fade-out, as documented in broader SEL literature. Given that the way that pupils are supported through self-discovery and introspection is crucial so that it remains psychologically safe is important, future studies could look at whether a universal school approach is more inclusive. Mixed-methods integration should continue, aligning quantitative trajectories with qualitative narratives through joint displays to refine CMO configurations, whilst also looking to investigate cultural appropriateness of the D\u0026amp;D in different groups. Finally, cost-effectiveness and equity analyses are essential to ensure scalability within resource-constrained local authorities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eYoung Dragons demonstrates that tabletop role-playing (TTRPG), narrative-based interventions can be delivered feasibly and acceptably within UK state schools serving pupils at risk of exclusion. Although statistically significant group-level changes in self-reported wellbeing were not detected, mixed-methods integration revealed mechanism-consistent improvements for many participants, particularly in self-management, cooperation, confidence and peer relationships, when delivery conditions were supportive. Outcomes were contingent on context, including facilitator skill, group stability and environmental predictability, underscoring the importance of implementation quality in creative, school-based mental-health interventions.\u003c/p\u003e \u003cp\u003eConsistent with staff narratives of calmer behaviour and fewer behavioural escalations, exploratory analysis of routine school data showed a significant reduction in suspensions and a modest, non-significant increase in attendance over the intervention period, suggesting potential indirect effects on behavioural stability even within a short timeframe. While these findings should be interpreted cautiously, they strengthen the plausibility that narrative, co-regulated play may influence downstream educational outcomes through improved emotional regulation and group functioning.\u003c/p\u003e \u003cp\u003eTaken together, this pilot provides a robust feasibility and mechanism-mapping foundation for a next-phase evaluation. Future studies should employ controlled or stepped-wedge designs, incorporate longer follow-up and link pupil-reported outcomes to administrative indicators such as attendance, behaviour and exclusion. With appropriate investment in facilitator training and delivery stability, TTRPG-based interventions such as Young Dragons may form a scalable component of inclusive, preventive mental-health strategies within contemporary school systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eARC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eApplied Research Collaboration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCASEL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCollaborative for Academic, Social, and Emotional Learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContext\u0026ndash;Mechanism\u0026ndash;Outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eD\u0026amp;D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eDungeons \u0026amp; Dragons\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEHCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEducation, Health and Care Plan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEAL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnglish as an Additional Language\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFree School Meals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGRAMMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGood Reporting of A Mixed Methods Study\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICREC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eImperial College Research Ethics Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLearning Support Assistant\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePupil Referral Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRBKC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoyal Borough of Kensington and Chelsea\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial and Emotional Learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEND\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecial Educational Needs and Disabilities\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial, Emotional and Mental Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIDieR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTemplate for Intervention Description and Replication\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTTRPG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTabletop Role\u0026ndash;Playing Game\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWestminster City Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e The study was approved by the Imperial College Research Ethics Committee (ICREC) (reference number ICREC #7802918). Adult participants provided written informed consent prior to participation. For pupil surveys conducted in schools, governance procedures were agreed with headteachers, and instruments were age-appropriate, brief, and administered in class settings with staff support. Anonymity was protected through the use of pseudonymous identifiers, and direct identifiers were removed from analytic datasets. Safeguarding procedures were followed throughout, and no adverse events were reported.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eG.H. and D.C. are directors of Mythic Minds CIC and were involved in the design and delivery of the Young Dragons intervention. All other authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e \u003ch2\u003eTwitter / X\u003c/h2\u003e \u003cp\u003e@austenelosta @ImeprialSCARU\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Austen El-Osta and Cornelia Junghans Minton are supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) Northwest London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.EO and C.J conceptualized the study. A.EO and Y.L conducted the literature review. A.A supported the development of the ethic submission pack. All authors (A.EO, S.A, Y.L, A.A, R.L, S.N, E.S, G.H, D.C, and C.JM supported the development of the data collection instruments. SA. conducted the quantitative data analysis. Y.L conducted interviews and contextual analysis with support from A.EO. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work. AE.O is the guarantor.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to acknowledge the support of all staff in participating schools and the parents of the pupils who participated in the intervention.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to ethical and governance restrictions. The study involves minors in school settings, and the quantitative survey data, qualitative interview transcripts, and routine school records contain information that could potentially enable participant or school identification if shared openly. Data access is therefore restricted under the terms of approval granted by the Imperial College Research Ethics Committee and data-sharing agreements with participating schools and local authorities. De-identified and aggregated data supporting the findings of this study may be made available from the corresponding author on reasonable request, subject to review of the request, approval by the relevant data controllers, and completion of appropriate data-sharing agreements. The survey instrument used in the study is provided as **Supplementary File 1.**\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eParker C, Ford T. Editorial Perspective: School exclusion is a mental health issue. J Child Psychol Psychiatry. 2013;54(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToth K, Cross L, Golden S, Ford T. From a child who IS a problem to a child who HAS a problem: fixed period school exclusions and mental health outcomes from routine outcome monitoring among children and young people attending school counselling. Child Adolesc Mental Health. 2023;28(2):277\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeale S. Half of pupils expelled from school have mental health issue, study finds. Guardian Newsp. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanders J, Liebenberg L, Munford R. The impact of school exclusion on later justice system involvement: Investigating the experiences of male and female students. Educational Rev. 2020;72(3):386\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObsuth I, Madia JE, Daniels H, Thompson I, Murray AL. The impact of school exclusion in childhood on health outcomes in adulthood: Estimating causal effects using inverse probability of treatment weighting. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGOV.UK. 'Suspensions and permanent exclusions - full year by geography' from 'Suspensions and permanent exclusions in England' 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://explore-education-statistics.service.gov.uk/data-tables/permalink/2fbcc48d-08c2-4dfd-a423-08dd8e33d0bf\u003c/span\u003e\u003cspan address=\"https://explore-education-statistics.service.gov.uk/data-tables/permalink/2fbcc48d-08c2-4dfd-a423-08dd8e33d0bf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeggs I, Denny S, Gregory L, Shaw H, Tindall H, Murphy S. Bi-Borough School Inclusion Strategy. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailey DH, Duncan GJ, Cunha F, Foorman BR, Yeager DS. Persistence and fade-out of educational-intervention effects: Mechanisms and potential solutions. Psychol Sci Public Interest. 2020;21(2):55\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGOV.UK. 'FSM eligibility by ethnicity or national curriculum year group' for Known to be eligible for free school meals in Kensington and Chelsea and Westminster between 2022/23 and 2024/25 2025 [cited 2025 Jul 20]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://explore-education-statistics.service.gov.uk/data-tables/school-pupils-and-their-characteristics/2024-25?subjectId=c46d3214-e869-4cee-4f5c-08dd736a5cea\u003c/span\u003e\u003cspan address=\"https://explore-education-statistics.service.gov.uk/data-tables/school-pupils-and-their-characteristics/2024-25?subjectId=c46d3214-e869-4cee-4f5c-08dd736a5cea\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJSNA. Mental health and wellbeing in Kensington and Chelsea, and Westminster. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers P. Contesting the Political: Violence, Emotion and the Playful Subject. Emotions: History Cult Soc. 2021;5(1):143\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldthuis M, Koning M, Stikkolorum D, editors. A quest to engage computer science students: Using dungeons \u0026amp; dragons for developing soft skills. Proceedings of the 10th Computer Science Education Research Conference; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerrick A, Li WW, Miller DJ. A study on the efficacy of the tabletop roleplaying game Dungeons \u0026amp; Dragons for improving mental health and self-concepts in a community sample. Games Health J. 2024;13(2):128\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenblad SR, Wolford T, Brennan RS III, Darnell J, Mabry C, Herrmann A. Mastering Your Dragons: Using Tabletop Role-Playing Games in Therapy. Behav Sci. 2025;15(4):441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtherton G, Hathaway R, Visuri I, Cross L. A critical hit: Dungeons and Dragons as a buff for autistic people. Autism. 2025;29(2):382\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCullinan M, Genova J. Gaming the systems: a component analysis framework for the classroom use of RPGs. Int J Role-Playing. 2023(13):7\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStubbs R, Sorensen N. Tabletop Role-Playing Games and Social and Emotional Learning in School Settings. Social Emotional Learning: Res Pract Policy. 2025;5:101016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePitt C, Chen K, Rubin J, Gibson D, Bindman S. How Youth Can Build Social and Emotional Skills with Tabletop Role-Playing Games. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOtani VHO, Novaes RA, Pedron J, Nabhan PC, Rodrigues TM, Chiba R, et al. Framework proposal for Role-Playing Games as mental health intervention: the Critical Skills methodology. Front Psychiatry. 2024;15:1297332.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartwig EK, Walker E, Stamman J. Roll for Initiative: Using Dungeons and Dragons in Play Therapy. J Creativity Mental Health. 2025;20(1):113\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolloy A. Supporting students wellbeing with Dungeons \u0026amp; Dragons 2024 [2025 Jul 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://thebuglenews.com.au/NewsStory/supporting-students-wellbeing-with-dungeons-dragons/662b605b076e190029c19dcb\u003c/span\u003e\u003cspan address=\"https://thebuglenews.com.au/NewsStory/supporting-students-wellbeing-with-dungeons-dragons/662b605b076e190029c19dcb\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatson A, Dungeons, Dragons, Skills D. How Tabletop Role-Playing Games Make SEL and Academics into an Adventure for Students 2023 [cited 2025 Jul 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nextgenlearning.org/articles/dungeons-dragons-durable-skills-sel-academics\u003c/span\u003e\u003cspan address=\"https://www.nextgenlearning.org/articles/dungeons-dragons-durable-skills-sel-academics\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarvasi P. How 'Dungeons \u0026amp; Dragons' Primes Students for Interdisciplinary Learning, Including STEM 2018 [cited 2025 Jul 22]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kqed.org/mindshift/51790/how-dungeons-dragons-primes-students-for-interdisciplinary-learning-including-stem?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://www.kqed.org/mindshift/51790/how-dungeons-dragons-primes-students-for-interdisciplinary-learning-including-stem?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagnier K, Okawa A, Jones-Manson S. Designing and implementing social emotional learning programs to promote equity. Designing and Implementing SEL Programs Equity White Paper; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGee B, Wilson J, Clarke T, Farthing S, Carroll B, Jackson C, et al. Delivering mental health support within schools and colleges\u0026ndash;a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents. Child Adolesc Mental Health. 2021;26(1):34\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg MT. Evidence for Social and Emotional Learning in Schools. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFusch P, Fusch GE, Ness LR. Denzin\u0026rsquo;s Paradigm Shift: Revisiting Triangulation in Qualitative Research. J Social Change. 2018;10(1):19\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu X, Gurung A, Baker RS, Barany A, editors. Understanding the Impact of Observer Effects on Student Affect. International Conference on Quantitative Ethnography; 2024: Springer.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"tabletop role-playing games (TTRPG), Dungeons \u0026 Dragons, social and emotional learning (SEL), school exclusion, emotional regulation, inclusion, adolescent mental health, mixed-methods evaluation, realist evaluation, self-management, teamwork, narrative-based intervention, at-risk pupils, UK schools","lastPublishedDoi":"10.21203/rs.3.rs-8357803/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8357803/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSchool exclusion in England disproportionately affects pupils with social, emotional, and mental health needs. Tabletop roleplaying games (TTRPGs) may strengthen social emotional learning but are rarely evaluated in UK state schools. Young Dragons, a Dungeons \u0026amp; Dragons based programme, was developed to support emotional regulation, teamwork, and engagement among pupils at risk of exclusion in two London boroughs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA convergent mixed methods realist evaluation was delivered across ten schools. Pupils aged 9\u0026ndash;16 attended weekly one-hour sessions for 6\u0026ndash;8 weeks in small, consistent groups. Pre/post pupil surveys captured wellbeing, self-concept, peer relations, school belonging, and loneliness; matched pair change (n\u0026thinsp;=\u0026thinsp;22) used Wilcoxon signed rank tests. Semi-structured interviews with school staff and facilitators and observation of multiagency meetings explored implementation and perceived impact. Findings were integrated using joint displays and context\u0026ndash;mechanism\u0026ndash;outcome (CMO) mapping.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo statistically significant within person change was detected across matched items (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.10). Distributions showed heterogeneous trajectories: many pupils reported better mood, anger regulation, and confidence, while a minority shifted toward greater disengagement or loneliness. Exploratory analysis of routine school records (n\u0026thinsp;=\u0026thinsp;30) showed a significant reduction in mean suspensions from 0.7 pre-intervention to 0.0 post-intervention (p\u0026thinsp;=\u0026thinsp;0.022) and a modest, non-significant increase in mean attendance from 90.6% to 92.7% (p\u0026thinsp;=\u0026thinsp;0.069). Qualitative accounts described strong engagement, psychological safety, and visible gains in self-management, turn taking, and teamwork, with positive spillover into classroom behaviour when groups were stable and facilitation was consistent. Delivery challenges included timetable pressures, space constraints, and stigma around targeted provision. Integration identified skilled facilitation, small-group safety, and structured reflection as key mechanisms enabling co-regulation, perspective taking, and belonging.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eYoung Dragons was feasible and acceptable in high need school settings. Benefits were mechanism-consistent for many participants but contingent on context and facilitator quality. These pilot data justify a larger, controlled evaluation to test causal pathways and longer-term outcomes for inclusion and emotional wellbeing.\u003c/p\u003e","manuscriptTitle":"Imaginative play for inclusion: Evaluating the Young Dragons tabletop role-playing intervention in UK schools","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:29:33","doi":"10.21203/rs.3.rs-8357803/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T01:38:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T07:35:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261835401660698263933871646335953317091","date":"2026-02-01T18:54:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T18:42:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122236229250574623952173947315873640390","date":"2025-12-31T16:15:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-30T18:05:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T13:29:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-29T04:00:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T17:41:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-12-26T17:34:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c21953ee-b873-41ab-99d8-e037407d5342","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T05:39:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 14:29:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8357803","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8357803","identity":"rs-8357803","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}