Developmental Considerations

Developmental Considerations in Conducting Behavioral Activation with Youth

 Youth are developing key coping skills and often experience co-occurring problems

  • Behavioral activation can be particularly relevant to problem-solving skills development in youth by helping them solve barriers to reward and practice activities that reduce risk for internalizing problems.
  • Comorbidity is more often the rule than the exception for youth psychopathology. For instance, anxiety and mood disorders often co-occur. Behavioral activation can help address a shared mechanism in anxiety and depression; namely, avoidance. The same is true for school avoidance and anxiety disorders in youth. Other considerations that may be pertinent to consider include co-occurring externalizing and learning disorders.

Youth clients have less control over their environment and activities than adults

  • Adults and school schedules often structure how children and adolescents spend much of their time, so youth activity level may not be as clearly linked to the youth’s personal feelings of activation as it might be in adults.
    • As such, low activation in youth may not look the same as it does in adults. Youth clients may be very “active” because they do not have a choice about staying engaged in school or activities, but that does not mean they are enjoying or deriving meaning from those activities.
    • More broadly, it is important to consider the role of contextual factors (e.g., family interaction patterns, parental mental health problems, separation and divorce, parent mental health problems, parenting style). Consideration should be given to the child’s education setting, including the potential role of school-based child assessment and intervention.

Caregiver involvement is key

  • When selecting activities for children and adolescents to do, the therapist must include an assessment of feasibility. This assessment should include awareness of cost and family resources, as well as what the clients’ caregiver will permit.
    • To help support low-resource families, therapists may want to seek out low-cost or free resources to facilitate behavioral activation in schools or community locations that are accessible to youth.
    • When trying to identify value-directed activities, the therapist must take into account both what youth and caregivers value. A shared decision-making approach can help identify activities that bridge any gaps that exist, consider developmental and functional level, and enhance cultural responsiveness.
  • Because of their important role, caregivers should be incorporated as much as possible into all phases of behavioral activation. This can be particularly important if the parent themselves has difficulty with activation.
  • Parents can have difficulty with the notion that when depressed youth are not doing things that they “should” be doing (e.g., homework), there may be still be benefit to still allowing them to engage in rewarding activities. Although parents may want to begin BA with “important” activities like homework, youth may be more engaged and more likely to do those activities down the road if behavioral activation starts on activities that are more intrinsically motivating and fit their developmental and functional level.
  • With adolescents, it can be tricky to think about how much to engage parents given their desires for autonomy. Peers may be a particularly good resource for activation with adolescents, if positive peer groups can be engaged in the process.

Youth clients may not enter treatment motivated to engage

  • Because youth clients may not be the drivers behind treatment referrals, they often enter treatment less motivated than a typical adult client. However, behavioral activation that starts by focusing on increasing activities that they like, and are affirming can often be a way to increase engagement by focusing treatment on things they find rewarding, rather than the goals that adults may have with them.
  • Keeping language and supporting materials attractive, engaging, and developmentally appropriate can facilitate treatment engagement and efficacy.
  • Youth clients may also enter treatment with less insight about their negative mood and why they make the choices they make. This may require more of a trial and error, less technical approach to behavioral activation that involves trying little things out and building a sense of youth efficacy to engage in new or valued activities over time.
  • Therapy homework compliance issues often arise for youth and may require special attention.
  • Technology, such as apps, can be a particularly relevant strategy for engaging youth in behavioral activation.

Some useful references

  • Martin, F., & Oliver, T. (2019). Behavioral activation for children and adolescents: a systematic review of progress and promise. European Child & Adolescent Psychiatry, 28(4), 427-441.
  • McCauley E., Gudmundsen G., Schloredt K., Martell C., Rhew I., Hubley S., Dimidjian S. (2016) The adolescent behavioral activation program: Adapting behavioral activation as a treatment for depression in adolescence. Journal of Clinical Child & Adolescent Psychology, 45(3), 291–304.
  • McCauley E., Schloredt K., Gudmundsen G., Martell C., Dimidjian S. (2011) Expanding behavioral activation to depressed adolescents: lessons learned in treatment development. Cognitive & Behavioral Practice, 18(3), 371–383.
  • McCauley, E., Schloredt, K. A., Gudmundsen, G. R., Martell, C. R., & Dimidjian, S. (2016). Behavioral activation with adolescents: A clinician’s guide. Guilford Publications.