What Is Behavioral Activation?
A form of therapy that uses activity to fight depression
Clinical Expert: Kimberly Alexander, PsyD
What You'll Learn
- What is behavioral activation?
- Why is it important to help kids identify activities they value?
- How does sticking to a schedule of activities help kids who are depressed feel better?
When kids are depressed, they often withdraw from activities that they usually enjoy. And missing out on things that make them feel good — spending a lot of time alone in their room instead of seeing friends, for example — makes their mood even more negative.
One technique therapists use to fight depression is called behavioral activation or BA. Behavioral activation is based on the idea that getting depressed kids to do things — even though they may not feel like doing them — can improve their mood.
In BA therapists work with the child or teenager to identify things they value doing, and steps they would need to take to do those things. These steps can be as simple as getting out of bed on time in order to go to school, or texting a friend. The child and the therapist make a detailed schedule for the child’s activities, and parents are enlisted to help make sure the schedule is followed.
Identifying what they value helps kids see how withdrawal and avoidance are not working for them, and how small steps towards goals that reflect those values can make them feel better.
BA can work for teenagers and kids as young as 7, though younger children usually need more support from parents to make and stick to the schedule. Sometimes rewards are used to help motivate kids to go through with activities.
When a child or teen is depressed, avoidance is often a symptom. Skipping family or social events, not being able to find the energy to get out of bed, neglecting school, passing on activities they used to enjoy: These are telltale signs that your child could be struggling with depression. And withdrawing from activities that normally make them feel good in turn reinforces their negative mood.
One technique therapists use to fight depression is called behavioral activation or BA. Behavioral activation is based on the idea that engaging depressed kids in activities — even though they may not feel like doing them — can improve their mood.
What is behavioral activation?
Behavioral activation involves working with a depressed person to increase activities that can reduce their depression. Research has shown that when someone engages in activities that generate positive feelings, the activities become intrinsically reinforcing, inspiring the person to do more of those things.
In BA, the therapist works with the child or teen to identify things they value and take steps towards those things they care about. “Let’s say you have a teenager who values spending time with their friends,” explains Kimberly Alexander, PsyD, a clinical psychologist at the Child Mind Institute. “But they’re so depressed they’re staying in bed, not going out, not responding to text messages, not engaging in social media. What we want to do is work with them on steps they need to take to get to be able to spend time with one of their preferred friends.”
Through focusing on the value they see in friendship, they might set goals like getting out of bed, taking a shower, and going to school where they will see their friends. “A goal might be to send just one text message today,” Dr. Alexander adds. “Or one text message in our session.”
Identifying their values helps kids see how withdrawal and avoidance are not working for them, and how small steps towards goals that align with those values — even if they’re as simple as getting out of bed and taking a shower — can make them feel better.
The therapist works with the child or teen, and their parents, to schedule activities. They also monitor how they’re doing on sticking to that schedule, and problem-solve together to resolve obstacles to increase their activity level.
Behavioral activation is often a component of broader treatment for depression or anxiety with cognitive behavioral therapy (CBT). But it has also been shown to be effective as a stand-alone treatment approach. BA is appropriate for children ages 7 and up, based on the individual child’s development and readiness. Readiness includes their ability to commit to engaging in treatment. “We have to gain the commitment from the patient to try,” explains Dr. Alexander, “or work on building commitment.”
How long does it take before a child doing BA experiences symptom relief? “I’ve seen change happen within about eight to 10 weeks of consistently meeting weekly and doing the work,” explains Dr. Alexander.
Two approaches to behavioral activation
There are two approaches to BA with distinct nuances. The first approach, called Behavioral Activation Treatment for Depression (BATD), is briefer, estimated to take 10-12 weeks. It emphasizes clarifying the child’s values, then basing activity goals on what matters most to the child. One child might value getting good grades, while another might value having friends who accept them for who they are.
Dr. Alexander notes, for instance, that for a transgender teen, being recognized as the gender they identify as can be an important value. “They often feel depressed whenever someone misgenders them. So for that teen, it would make sense to take steps towards having friendships with people who are gender affirming.”
By contrast, the second approach, traditional behavioral activation, typically includes something called a functional behavioral analysis (FBA). That’s a technique for analyzing things the child is avoiding — things they need to do, like getting ready for school on time in the morning, and things that they once enjoyed, like playing basketball with their friends — to see what may be contributing to the avoidance. The therapist gathers information about what happens before the avoidant behavior occurs as well as what could be reinforcing it — making the behavior reoccur in the future. For example, the therapist might notice that when the child refuses to get out of bed, a parent will come and sit with them until they do, providing attention that the child might seek out again the next day. By understanding the function of the behavior, the therapist can make a plan to help change it.
How is behavioral activation implemented?
Here is what you might expect during a child’s course of treatment with behavioral activation.
- Reflect on daily activities: BA begins with what is known as activity scheduling. The child or teen will work with the therapist and support from parents, to outline what their daily schedule looks like currently, from the time they wake up in the morning to the time they go to sleep at night.
- Identify activity goals: The therapist and child or teen work together to identify activities that they’re interested in, whether they are new activities or things that they used to do in the past, as well as steps to move toward those goals. In many cases, a step towards the things they value involves getting out of bed when the alarm clock goes off. “When I’m working with teens,” says Dr. Alexander, “I really want to tap into what the teen’s personal interests are.”
- Create a written plan: Dr. Alexander comes prepared with a printed daily schedule and invites the child or teen to write in their activities for each hour block throughout the day. Older kids may prefer to use the calendar or notes app on their phone. The important piece is getting the plan down clearly in writing, and then sharing it with parents for accountability and monitoring.
- Build skills needed for success: It’s important to note any skills that need to be developed in order for the child to be successful in carrying out their activity goals. “If one of the things the child needs to do is complete reading assignments, and the child is dyslexic,” Dr. Alexander explains, “the child will need some scaffolding. We have to figure out, is this book engaging enough? Is this book at their reading level? Do they need support or a reinforcer around that book in order to encourage their reading time?”
- Identify reinforcers: Using rewards can help motivate the child or teen to follow through with the desired behavior. For example, a parent could reward a child with extra screen time for engaging in a scheduled activity.
A case study in behavioral activation
Harnessing the power of a child or teen’s personal interests can be the key to making BA most effective. When working with a 14-year-old girl with depression and suicidal ideation, Dr. Alexander discovered that her after-school activities were minimal. “She was actually experiencing a lot of conflicts with her peers in school and then after school, they weren’t interested in the same things that she was interested in. Her parents reported that she would stay in her room for hours on end.”
Dr. Alexander discovered that her patient loves basketball, but she had no one to play with and she didn’t want to go out by herself. The teen said that it was actually her dad who introduced her to basketball. “We were able to schedule time after school for her to shoot baskets with her dad,” Dr. Alexander says, “and having this to look forward to at the end of the day helped her get out of bed and go to school. She admitted that she didn’t even enjoy spending all day in bed, and her mood improved.”
Challenges in implementing behavioral activation
Sometimes underlying beliefs emerge as a challenge that stands in the way of a child or teen successfully meeting their activity goals. Dr. Alexander has noticed a fear of failure in some clients that makes the word “goal” aversive. “I’ve definitely had some patients tell me, ‘I don’t like the word goal. To me, it triggers a sense of failure, that I will likely not accomplish what it is that I’m setting out to do. And what if I don’t? What would that mean about me?’”
Dr. Alexander responds by reframing the thinking to what she calls “a growth mindset” that recognizes progress. “For example, I might say, ‘If you did a minute out of 30 minutes of reading, that’s not failing. That is a minute, and that is more than what you did yesterday,’ ” she says. Finding another word to replace “goal” can also be powerful. Dr. Alexander has used the term “guided intention” to help clients to feel more supported by the language being used.
Another important factor to consider is whether or not the family has the time and resources to support BA. “We also have to consider how feasible it is for the patient to access the resources they need for whatever the activities are,” explains Dr. Alexander. “If their parents are very busy, working multiple jobs and therefore may not be available at times when their support would be helpful — all of those other factors have to be considered in the treatment planning phase.”