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Changing Maladaptive Behaviors, Part 2: The Use of Behavioral Activation and Pleasant Events Scheduling with Depressed Children and Adolescents

Sandra L. Mendlowitz

Introduction

The landscape for treating depression has been slowly shifting in recent years. While the efficacy of cognitive behavioral therapy (CBT) for depression – as well as for other internalizing disorders – has long been established in both adults and children (Beck, Rush, Shaw, and Emery 1979; Bhar and Brown 2012; Deckersbach, Gershuny, and Otto, 2000; Kazdin and Weisz 1998; Lewinsohn, Rohde, and Seely 1998), behavioral activation (BA) is emerging as an effective technique that is as successful as CBT (Butler, Chapman, Forman, and Beck 2006).

While there are some clinical variations in CBT, the critical components involve cognitive restructuring, problem solving, and anxiety management techniques. Developmental considerations are almost always made, as the concept of challenging maladaptive thoughts is developmentally challenging for youth. As in the treatment for adolescent depression study (TADS) (March and Vitiello 2009), CBT interventions for youth almost always involve social skills training, behavioral strategies, and concrete examples to help the client navigate through the therapy. A component analysis of CBT for depression demonstrates that it actually involves a large behavioral activation component. The utility of the cognitive component in CBT, however, has been questioned by a number of authors (Gortner, Gollan, Jacobson, and Dobson 1998; Hollan 2001; Jacobson, et al. 1996; Longmore and Worrell 2007). One of the main reasons for this challenge is that the introduction of the cognitive components of CBT often happens later in the process, when mood symptoms have already improved. This trend has been noted across studies (Longmore and Worrell 2007). Further evidence for the importance of behavioral activation was brought by McManus, Van Doorn, and Yiend (2012), who examined two components of CBT – thought records and behavioral experiments challenging and changing the participant’s beliefs – by using a single-session model. While both methods resulted in improvement, the behavioral experiment group obtained greater gains.

One of the most compelling pieces of evidence for the use of BA for depressed youth is from the TADS team (March and Vitiello 2009; Ritschel, Ramirez, Jones, and Craighead 2011; Treatment for Adolescents with Depression Study 2007). The study involved 432 moderately to severely depressed adolescents (12 to 17 years old) who were randomized into one of four conditions (placebo, fluoxetine, CBT alone, and CBT plus fluoxetine). In the initial phase of treatment the adolescents were taught about mood monitoring, pleasant activity scheduling, identification of cognitive distortions and thought challenges; optional strategies included relaxation strategies and mood regulation (Rhode, Reeny, and Robins 2006). In the next phase of treatment the adolescents were engaged in social skills training. While the final conclusion indicated that CBT plus medication was the most efficacious, results also suggested that TADS CBT was helpful in preventing relapse. Ritschel and colleagues (2011) noted that, unlike in traditional models of CBT, here there was a significant emphasis on the behavioral components of the CBT, which underscored the unique contribution of BA.

Foundations of Behavioral Activation

From a chronological perspective, behavioral therapies (BT) have earlier roots (Pichot 1989; Wolpe and Lazarus 1966) than cognitive therapies, which emerged in the early 1970s (Curran, Ekers, and Houghton 2011; Mahoney 1977). Wolpe (1958) was the pioneer of behavioral models of therapy. His techniques were developed from models of Pavlov’s classical conditioning and were primarily focused on the treatment of anxiety disorders, where Wolpe successfully introduced the concept of systematic desensitization. Lazarus (1968) utilized these concepts and applied them to the treatment of depression (Curran et al. 2011). He noted that behavior therapists largely ignored the concept of depression. He, however, conceptualized depression as arising from a stimulus–response pattern. He theorized that depression was caused either by a lack of positive reinforcements or by reinforcements that had lost their effectiveness – a view shared by other behaviorists (Lazarus 1974).

Ferster (1973) and Lewinsohn (1974) both conceptualized depression in terms of positive and negative reinforcement, and this formed the basis of what is now called BA. Specifically, the underlying assumption is that, when depressed, the individual avoids positive events and thereby will experience few rewards or positive reinforcers (Ferster 1973). This results in a downward spiral, as the individual continuously removes him-/herself from perceived aversive situations and becomes more withdrawn and isolated. Consistent with this theory, Lewinsohn (1974) further suggested that a lack of positive rewards – in other words, fewer positive social interactions, due either to behavior or to the lack of social skills (Lejuez, Hopko, LePage, Hopko, and McNeil 2001) – maintains this depressive cycle and that an infusion of positively rewarding experiences was necessary to offset the cycle. He noted that skills learning was necessary to increase engagement. Lewinsohn proposed the use of pleasant events scheduling (PES), which was critical to BA: in PES positively rewarding activities were built into an individual’s weekly schedule at hourly intervals, with the goal of increasing the opportunity for rewarding experiences (Martell, Dimidjian, and Herman-Dunn 2010).

In contrast, cognitive therapists conceptualize depression as emerging from maladaptive thoughts, whereby sufferers experience a negative view of the self, the external world, and the future (Beck et al. 1979; Kazdin and Weisz 1998). Depressed individuals select out negative stimuli and therefore their memory of events is biased toward negative patterns. Cognitive therapy (CT) focuses on the modification of faulty patterns or negative bias of thinking (Shaw 1977).

CBT techniques incorporate not only components involving the thinking process, such as distortions in thought, but also components related to cognition and behavior. Key to this perspective is the link between thoughts, emotions, and behaviors. CBT techniques involve more than a systematic modification of thought patterns; namely they also involve the concept of challenging the negative thoughts through behavioral experiments (McManus et al. 2012). CBT has been associated with a rapid response, both in adults (Longmore and Worrell 2007) and in children (McManus et al. 2012). The techniques have been widely adapted to many types of mental health problems, and there is a significant number of evidence-based protocols that have been developed for both adults and children (Klein, Jacobs, and Reinecke 2007; Treatment for Adolescents with Depression Study 2007).

While all of these therapies, which differ in their tenets, have demonstrated some effectiveness with respect to outcome, none is unique, except in its method of approach. While behavioral therapies focus on the learned experience, cognitive therapies focus on the influence of thoughts. All seek change through a modification of the way one perceives the environment. Hence an understanding of each of these types of interventions will yield a greater overall understanding of BA. Figure 15.1 draws a comparison between the four therapies described above: behavior therapy, cognitive therapy, cognitive behavioral therapy, and behavioral activation.

c15-fig-0001 — **Figure 15.1** Comparison of models of depression.

Adapted from Wolpe and Lazarus (1966); Beck, Rush, Shaw, and Emery (1979); and Ritschel, Ramirez, Jones, and Craighead (2011).

Key Features of Competencies

Several key areas of competence are required for the successful application of BA, including a thorough understanding of the theoretical underpinnings of BA and knowledge of how to conduct a BA assessment and subsequently apply the five core treatment components. Finally, appropriate understanding and use of PES remains a critical component of this competency.

Behavioral activation, defined

Behavioral activation is a type of behavior therapy for depression that targets the level of activity through focused activation strategies (Jacobson, Martell, & Dimijian, 2001; Sturmey, 2009). The theoretical underpinnings are borrowed from behavioral models of depression (Ferster 1973; Lewinsohn 1974). The general model suggests that low levels of positive experiences (rewards), coupled with high levels of negative experiences (perceived punishment), result in depressed affect. When BA is applied to depressed youth, it appears that children and adolescents experience depression because they focus on negative experiences rather than on rewarding or positive experiences. The model assumes that avoidance of activities interferes with the experience of positively reinforced situations (Kanter, Puspitasari, Santos, and Nagy 2012; McCauley, Schloredt, Gudmundsen, and Martell 2011). When positive reinforcement is blocked through avoidance and the individual’s ability to experience pleasurable activities is hindered, depression can develop (Ritschel et al. 2011). Depressed individuals are more likely to attend to negative or aversive situations and to diminish their opportunities of engaging in pleasant activities that can result in positive reinforcement (Martell et al. 2010). They tend to use avoidant coping, which results in low positive reinforcement (Jacobson et al. 2001). Avoidance also limits the possible ways in which one could respond to a situation, creating additional stresses in an individual’s life (Jacobson et al. 2001). Therefore the goal of BA is to help activate the person so that (s)he will be more likely to experience his/her behavior in ways that would be positively reinforcing and to re-engage in activities that (s)he once found pleasurable. This is largely accomplished through activity scheduling (Martell et al. 2010). (PES and activity scheduling are used interchangeably and will be explained below.)

Behavioral activation assessment

The process of BA assessment is one of reviewing the individual’s situation and life events and his/her responses to the latter when depressed. Assessment typically involves a formal evaluation of depressive symptoms and the use of self-report questionnaires to measure mood (e.g., through an instrument like the children’s depression inventory: see Kovacs 1992). The use of objective measures is important, as the measurement obtained will serve as a baseline for measures of change after treatment. Less formal but imperative evaluations include: an understanding of daily activities (e.g., a daily activities list); activities currently avoided (number, intensity, patterns); any changes in activity levels (academic, family, peer-related, leisure); and immediate as well as long-term activities that the individual finds reinforcing. Assessment also includes an evaluation of potential triggers of depressive feelings, resultant behaviors, and consequences of these behaviors – both in the short and in the long term. These components are important in the development of appropriate and realistic – that is, obtainable – goals during the intervention phase.

Behavioral activation intervention

Jacobson and colleagues (1996: 297) identified five core elements of BA:

monitoring daily activities and assessing the pleasure and mastery involved;
assigning new daily activities to increase pleasure and mastery;
imaginal rehearsal of activities before they are undertaken;
problem solving any barriers to undertaking new activities;
interventions to address social skills deficits such as assertiveness and communication training.

While core elements guide the principles of BA, activation is the most fundamental and important component (Antonuccio 1998; Bottonari, Roberts, Thomas, and Read 2008; Carvalho and Hopko 2011; Deckersbach et al. 2000; Gortner et al. 1998; Hollan 2001; Martell et al. 2010).

Pleasant events scheduling

Pleasant events scheduling is part of the weekly activity monitoring that is critical to successful implementation of BA. It is either a self-directed or therapist- or parent-assisted list of positive or reinforcing activities. While a validated scale has been created for adults (e.g., the pleasant events schedule: see MacPhillamy and Lewinsohn 1982), no empirically validated scale currently exists for children. Table 15.1 offers an example of a PES list.

Table 15.1 Pleasant events list and rating.

Activity	Potential levelof enjoyment 0–10	Used to enjoy	Would like to try
Playing video games	9	√	√
Reading a book	6		√
Playdate	8	√	√
Going to soccer	10	√	√
Watching football with my dad	5		√
Exercising at the gym with my friends	7		√
Going to a restaurant with my family	7	√	√
Going to the ice cream store	6	√	√
Shopping with my friends	10	√	√
Getting my homework assignments in on time	7		√
Watching my favorite TV show	7	√	√
Sitting with others at lunch	8	√	√

The schedule should include a column for the target activity, potential level of enjoyment (which can be adjusted during the course of treatment; using an intensity scale of 0–5 for young children and 0–10 for school-aged children or adolescents), previously enjoyed activities, and potentially enjoyable activities that the individual would consider a target goal. Given that individuals with depression have a bias toward negative thinking, it would not be unusual for a child or adolescent to underestimate how enjoyable an activity is; as such, using pre-post-ratings is important and will help provide evidence to challenge pessimistic attitudes (Friedberg and McClure 2002). One method of helping a resistant child or adolescent participate in the process is to develop short-term achievable goals coupled with incentives for effort. Table 15.2 is an example of a PES log and Table 15.3 is another general type of activity log.

Table 15.2 Pleasant events schedule (PES) and activity log for youth.^a

*ACTIVITY*	*DAY 1*	*DAY 2*	*DAY 3*	*DAY 4*	*DAY 5*	*DAY 6*	*DAY 7*
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
	AM
	AFT
	PM
^aAM = morning; AFT = afternoon; PM = evening. Rate the mood before and after the activity, on a scale of 0–10 where 0 = unhappy and 10 = very happy. Indicate the amount of time spent in the activity: e.g., AM – mood = 5; amount of time = 20 mins.

Table 15.3 General activity log for youth.

*Time of day*	*Sunday*	*Monday*	*Tuesday*	*Wednesday*	*Thursday*	*Friday*	*Saturday*
7:00	sleep	hockey practice		hockey practice	swim meet	hockey practice	sleep
7:30	sleep				swim meet		sleep
8:00	sleep		school	school			sleep
8:30	sleep	school	school	school	school	school	sleep
9:00	sleep	school	school	school	school	school	sleep
9:30	sleep	school	school	school	school	school
10:00	sleep	school	school	school	school	school
10:30		school	school	school	school	school
11:00		school	school	school	school	school
11:30		school	lunch	school	lunch	school	movies
12:00		lunch	lunch	lunch	lunch	lunch	movies
12:30	swim lessons	lunch	school	homework	school	lunch	movies
1:00		school	school	school	school	school
1:30		school	school	school	school	school	sleep
2:00		school	school	school	school	school	sleep
2:30		school	school	school	school	school	guitar
3:00		school	school	school	school
3:30		school		school	school
4:00
4:30		walk dog		homework	homework	TV
5:00	dinner		math tutor			TV	walk dog
5:30			TV		dinner	PS3 with Matt	walk dog
6:00	homework	dinner	dinner	dinner	dinner	PS3 with Matt
6:30		homework	dinner	homework		PS3 with Matt
7:00		homework	TV	homework	TV		dinner
7:30		homework	homework		TV		dinner
8:00			homework		homework
8:30	guitar	guitar	guitar	sleep	guitar
9:00	homework	homework		sleep	guitar		guitar
9:30	homework	homework		sleep
10:00	homework			sleep			friends
10:30				sleep			friends
11:00				sleep	homework
11:30			sleep	sleep	homework
12:00		sleep	sleep	sleep	homework

It is important that the person-specific pleasant events list is developed so as to be appropriate for the developmental stage and learning style of the child or adolescent (e.g., in how the target goals are set for activities, or in how information is recorded). Filling in this log should not become an onerous task for the child, since compliance is critical. It is also important that the activity should not inadvertently maintain avoidance patterns; so, for example, while reading a book may be a pleasurable activity, it has the potential to function as an escape mechanism – so this potential would need to be evaluated. Since depressed youth generally withdraw from activities, the PES is a way to assist them with engaging in rewarding experiences, increasing their level of activities, and helping to guard them against social withdrawal (Friedberg and McClure 2002).

Competence in Treating Anxiety Disorders and Depression

Below is the example of an individual case.

Susan is a depressed and anxious 11-year-old. She stopped participating in afterschool programs when her best friend changed schools. While she was quite willing to complete her anxiety-based CBT homework, she developed a strong resistance to engage in previously enjoyed sports activities, preferring to stay at home and read books. While she enjoyed reading, the activity served to isolate her from peers and to reinforce social withdrawal. A plan was developed to reintegrate Susan back into afterschool programming. Incentives were offered for completing activities and for providing pre-post ratings. Through increasing social interactions, Susan was more amenable to engaging in other activities.

It is important to understand that anxiety and depression tend to be comorbid disorders, especially in youth. Avoidance is a component of both anxiety and depression; although the reasons for the avoidance differ vastly in each condition, in both cases they are negatively reinforcing. In anxiety disorders, avoidance is used as a way to escape a feared situation and results in relief, thereby negatively reinforcing itself. For example, Susan is afraid that people would laugh at her speech, so she pretends she is ill and doesn’t attend school. Her stomach aches disappear when she is at home. In other words, when children remove themselves from fearful situations, their anxiety diminishes; hence they learn to avoid rather than face their fears. In contrast, avoidance in depression has more to do with removing an individual from the environment and its perceived difficulties. For example, Susan thinks her speech is not good and can never be as good as that of others, so there is no point in even trying to write the speech; hence she doesn’t attend school, sleeps all day, but feels worse. In depression the avoidance does not result in relief, because the problems still exist; avoidance is negatively reinforced. Essentially, avoidance serves to allow the youth to maintain their depressed mood, as the avoidance leads to low mood, negativity, and loneliness.

In summary, the primary targeted behavior in both anxiety and depression is avoidance, although this behavior is manifested in very different ways in each disorder. In depression, BA targets the negatively reinforcing experience of depression by increasing the number of rewarding experiences. In anxiety, avoidance is addressed, in contrast, by confronting the feared situation.

Implementation of behavioral activation

It is important to underscore the key assumption of BA theory: depression is caused by situations (e.g., a family move, peer rejection, parental arguments); these are called “activating events.” Since there is little – if any – positive reinforcement for these events, they increase one’s vulnerability to depression. Avoidance develops as a way of escaping the activating events, but it is negatively reinforcing; and thus the pattern of inactivity is maintained – with its inherent fatigue, apathy, and loss of interest. PES is the approach used to increase activity levels (Jacobson et al. 2001; Lejuez et al. 2001; Martell et al. 2010). Increasing normal peer-related activities by diminishing social withdrawal is an important component of BA in youth (Friedberg and McClure 2002).

BA must be implemented in a stepwise approach in order for the client to achieve mastery. Breaking down goals (pleasant activities) into manageable steps is critical for self-reinforcement. The assignment of activities should be revised as needed, to confirm that they are achievable (Jacobson et al. 1996; Lewinsohn, Clarke, Hops, and Andrews 1990; Martell et al. 2010). If the child or the adolescent is extremely negative, motivators need to be addressed. Everyone is motivated by something; the key would be to determine what motivates that particular child. Very young children may be motivated by simple rewards (stickers, candy, etc.); teens may need other types of motivators. For example, use of electronics (amount of time and specific electronics) may be earned by engaging in agreed-upon activities.

Social skills training is an important component in the BA intervention for youth. A target goal for depressed youth frequently involves social interactions with peers. Social skills training can enhance positive peer interaction and is therefore clinically relevant. In order to bring about behavior change through a positively reinforcing activity, the youth must be viewed as responding in socially acceptable ways (Kazdin 1977). This can be problematic, as peer interactions are challenging for depressed children or adolescents. Educating youth through direct instruction, through role-play, or by problem-solving peer conflict and building in youth skills appropriate for social interaction – these two actions enhance the youth’s confidence to engage in social interactions with peers (Friedberg and McClure 2002).

Competence in Treating both Children and Adolescents

Prior to the initiation of any therapy, a concise and detailed diagnostic assessment that includes self-report measures of depression is essential. In the case of youth, parental involvement in both assessment and intervention is critical. Unlike adults, youth are usually brought to treatment by their parents. While parents may not always know what their children are thinking, they are present to observe behavior and therefore can give the therapist valuable input regarding avoidant behaviors, responses to homework, and degree of social interactions. They are also integral to the facilitation of behavioral activation; they help enhance the PES; and they provide coaching for youth, both during treatment and after its termination. The research literature has repeatedly demonstrated the profound effect that parents can have on the successful outcome of treatment (Lewinsohn et al. 1990; Mendlowitz et al. 1999; Wells and Albano 2005).

Parents play a vital role in the development of the youth’s PES, especially when one is treating very young children, and they can have a profound effect on the successful outcome of treatment (Lewinsohn et al. 1990; Mendlowitz et al. 1999; Wells and Albano 2005). Parents may facilitate the recording of the information and may help create a list of pleasant activities, especially when these involve the family and play dates with peers or relatives. Depressed youth tend to express a negative bias toward unpleasant activities and need support in identifying pleasant events. These lists should be constantly revised as target goals are met. Support may be required until the youth begins to shift his/her cognitive bias toward pleasant activities. Additionally, parents may be required to facilitate activities for adolescents, for example by arranging to transport them to activities within and around the community – but also outside their local area.

Parents may also assist in the identification of social skills deficits that interfere with successful outcomes. As a welcome addition to what is achieved therapy, parents and siblings may help the depressed youth by role-playing and modeling participation in pleasant activities, so as to facilitate the learning of social skills (Hansen, MacMillan, and Shawchuck 1990). As noted, this self-monitoring task should be passed on to the youth, to help them develop independence and to instill confidence. Overall, parents can play a significant role in positive reinforcement from the provision of verbal encouragement, rewards, record keeping, and overall support.

Steps in behavioral activation with children and adolescents

The steps involved in BA therapy are: (1) understanding depression in the context of the BA model; (2) understanding activation, building a PES, developing an activity and mood log; (3) social skills and problem solving; (4) ongoing practice; (5) feedback and modification of activities; and (6) relapse prevention (Dobson et al. 2008; Lejuez et al. 2001; Martell et al. 2010; McManus et al. 2012; Ritschel et al. 2011; Trew 2011).

Understanding depression in the context of the BA model The role of avoidance in depression is not an easily understood concept. Laying the groundwork for any therapy is in itself a valuable tool for facilitating commitment and adherence to the protocol, because the therapy is a collaborative approach between child or adolescent, parent (depending upon the age and developmental level of the youth), and therapist. Specific goals are outlined in the initial sessions. The framework of the sessions, of expectations, and of session outlines is reviewed – as well as the framework of homework expectations.
Understanding activation, building a PES, and developing an activity and mood log: Providing an explanation of activity as a mediator of change The purpose of activity – to increase energy levels, facilitate clear thinking, create opportunities for positive experiences, and provide ways to engage in situations – is discussed. Activities that both enhance and diminish mood are reviewed. Activities are planned and scheduled. PES is developed and self-monitoring techniques are illustrated. Figure 15.1, Table 15.1, Table 15.2, Table 15.3, and Figure 15.2 are examples of logs that can be utilized for both children and adolescents.
Social skills and problem solving Both social skills and problem-solving strategies facilitate positive social interactions and are important steps toward forming positive peer relationships. These relationships are critical in the maintenance of mood.
Practice Both in-session and assigned practicing of skills (i.e., in homework) are part of an ongoing process. Support, responsibility for practice, frequency, and monitoring are discussed. Practice is an opportunity to reinforce positive outcomes.
Feedback and modification of activities Communication between the therapist, the child or adolescent, and the parents is critical for overcoming any barriers in the target activities. The goal is to break negatively reinforced patterns of behavior. To achieve this, targets must be set and modified as needed, so that the target goal can be accomplished and positively reinforced.
Relapse prevention As in all therapies, prior to termination a review of triggers and effective strategies is made. Planned booster sessions are arranged.

Specific activation strategies outlined by Jacobson and colleagues (2001) are focused activation, graded task assignment, avoidance modification, routine regulation, and attention to experience. While these strategies were described for use with adults, they can also be useful in working with youth.

c15-fig-0002 — **Figure 15.2** Conceptualization model of CBT with BA for depressed children and adolescents.

Given that depressed youth tend to avoid activities that may help them feel better, the process would be to identify what the youth previously enjoyed and to have them re-engage in those activities (this would be called focused activation). Such a process facilitates pleasure and breaks the cycle of negative reinforcement, because the individual achieves positive reinforcement through activity (see Figure 15.1). Working with both the youth and the parent to decide what activities would be best suited to initiate activation facilitates the process.

It is widely recognized that behavioral experiments are designed to be success-oriented. In view of this, activities should be designed to maximize success. Activities that are easy to engage in will provide positive reinforcement and will motivate the individual to eventually engage in more challenging activity steps. For youth, external rewards (e.g., parental praise, small gifts) are valuable motivators to encourage effort, especially when they feel challenged.

To explain an avoidance pattern to youth, especially young children who are experiencing depression, is not an easy task. However, this is an important concept for youth to understand as part of the mechanism of change. One method would be to define the child-specific pattern of avoidance that may be maintaining their mood. For example, the experience of being bullied at school leads to avoidance of peers, and hence to loneliness and low mood. Learning skills to cope with bullying, attending school, and participating in fun school activities will make it easier to attend school, make friends, and be happier.

In our previous example, Susan had been the victim of bullying. When her best friend left the school, she feared her previous history of being bullied would recur. It was difficult for her to believe that she could engage in other positive peer relationships. The goal was to make her engage in activities where she could have positive peer interactions. Activities where she showed a high level of skill, coupled with social skills training, helped her to agree to participate in these activities. Once she engaged in them, the positive interactions reinforced ongoing participation, she eventually developed other peer relationships, and her mood improved.

Maintenance of routines and consistency, while an important strategy in BA, is also a healthy strategy for youth. Being able to anticipate situations is positively reinforcing to youth, because it enhances the person’s capacity to reduce negative interactions.

As previously noted, depressed youth have an attentional bias to negative stimuli and, as a result, they engage in rumination that can interfere with perception of change. For example, a teen may claim that, in spite of spending time with his or her peers in the lunchroom and other places in the school, (s)he does not feel any change in his/her mood. In this scenario, the therapist would need to dismantle the situation to discover that, although the youth is present in the company of peers, (s)he continues to isolate him-/herself from peers – say, by not actively engaging in discussions.The task would then be to redesign the activity so as to include interaction with peers.

BA and CBT

While all of the aforementioned components are critical to the model of BA, there is some variation in the number of sessions and in the dissemination of the therapy. Moreover, the administration of therapy requires skill acquisition in order to be successful (Lejuez et al. 2001; Lewinsohn et al. 1990; Martell et al. 2010; Trew 2011). Although BA therapy is a very promising intervention with strong research evidence to suggest that it is effective, a closer examination of interventions (e.g., Ritschel et al. 2011) suggests that an integrated approach that includes both cognitive interventions and BA has been more successful than BA alone (Lejuez et al. 2001; Martell et al. 2010; McManus et al. 2012).

Figure 15.2 represents a model of integration of CBT and BA for children and adolescents. In Beck and colleagues’ (1979) model of CBT there is a triad relationship (see Figure 15.1). These relationships are interconnected, so that changing any one of them changes the others. Depression develops from a set of dysfunctional or mistaken beliefs. Depression is maintained through negative views of the self, the world, and the future. In the BA model (Lewinsohn et al. 1998), depression arises from a lack of engagement in the environment (e.g., school, home) – a lack that, like in Beck’s model, is also cyclical in nature. According to this model, depression can develop as a result of situational factors such as poor academic results, and is maintained through patterns of avoidance. Both CBT and BA strive to improve mood state by changing the patterns of behavior, which is facilitated through the learning of very specific skills. Through behavioral activation, the individual challenges inactivity in order to change his/her mood. Activity leads to more positive reinforcement and less depressive symptoms; an increase in positive emotions helps one shift to more helpful attitudes and beliefs (Lejuez et al. 2001), and therefore the integrated model has some useful perspectives on treating depressed youth.

Common Obstacles to Competent Practice and Methods to Overcome Them

As in any treatment intervention, the motivation for change is an important component. Finding this motivation may be difficult for the depressed child or adolescent. It has already been noted that parents play a significant role in treatment outcomes for youth. Generally speaking, the younger the children, the less autonomous they are in treatment; therefore children require more parental involvement than adolescents – although parents do need to be involved at all stages of development.

So take a child who is depressed: how do you get him/her involved in BA, especially when (s)he may not be motivated to do anything?

Establish with the child or adolescent that they are following an activity plan, not an inactivity plan. This means that they will be required to follow the plan, not their mood. Any step forward is a step in the right direction. Creating small activities to initiate the start of the plan is critical.
Teach the parents not to engage in emotional responding. For example, when youth do not want to engage in an activity, they often resort to threatening their parents with self-harm or aggression. Parents often feel vulnerable; to activate a child who threatens self-harm or aggression or who does not feel motivated to move is counterintuitive. Parents then resort to becoming overprotective and overconcerned out of love, but they do not realize that they are enabling their child, which serves to increase the avoidant behavior. This is true for both anxiety and depression.
Always remember to keep steps manageable for both parents and youth. Change should always be incremental. Positively reinforcing both parents and youth for their efforts helps to motivate compliance.
Ask both the parent and the youth what they will achieve by engaging in the treatment. If the depressed youth responds with “nothing,” work toward an understanding of potential change (benefits and lesser benefits), then help them to monitor changes in mood so that they may identify these benefits.

Conclusion

BA is an increasingly recognized treatment for depressed youth. Like in any treatment intervention, specific competencies are required in theoretical knowledge, and also an appropriate assessment and application of the technique. Graduated and developmentally sensitive approaches to treatment are necessary when adapting BA to children and adolescents. While there are obstacles involved in the use, for youth, of BA with parental involvement and proper therapist training, this represents a promising approach to treating depressive symptoms in youth.

References

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