BHIPP Bulletin
Volume 7, Issue 7
January 2022
Combating Youth Depression with Behavioral Activation
This month's BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant. Additionally, this month's BHIPP Resilience Break focused on "Diagnosing and Managing Seasonal Depression in Primary Care" and was presented by Alden Littlewood, MD, Child and Adolescent Psychiatrist and BHIPP Consultant and Kelly Coble LCSW-C, BHIPP Program Director. To view the full session recording, slides, and related resources: click here!
Behavioral activation is a psychosocial intervention to consider when youth display depressive symptoms. Behavioral activation is a specific technique that is a central component of cognitive-behavioral approaches to improving mood and reducing depressive symptoms. The mechanism of Cognitive Behavioral Therapy (CBT) emphasizes understanding the association among thoughts, feelings, and behaviors/actions as a way to change moods and behaviors. We can teach adolescents to engage in positive activities and behaviors to enhance moods and feelings. Fun, rewarding, enjoyable, and social activities lead to positive emotions and pleasure, and engaging in those activities may reinforce a person’s motivation to continue pursuing those activities. Research with adults indicates that behavioral activation can function as an effective anti-depressant tool, and emerging research with adolescents is likewise encouraging. Our collective experience during the COVID pandemic underscores the possible reasons why: it turns out that maintaining one’s normal mood and motivation depends on regular engagement in enjoyable activities that ideally involve socializing with our friends. Take away routines, hobbies, and social contact, and many folks begin to feel down.
As depicted in the diagram below, behaviors influence emotions, just as emotions affect behaviors/actions. We often depend on our feelings to prompt our behavior. Do I feel like exercising? Do I feel like flossing? In the case of depression, a teen may lack motivation to engage in activities that typically lead to positive feelings (e.g., becoming socially isolated or withdrawn, not hanging out with friends), or a depressed teen may stop engaging in activities that indirectly boost self-worth and mastery (e.g., completing homework on time, attending sports practice, playing a musical instrument). 
With behavioral activation, we want to activate mood-enhancing behavioral experiences to change a teen’s emotional experience. Within our CBT perspective, we can teach teens that actions can activate emotions… just like emotions (e.g., sadness) can de-activate behavior (e.g., calling a friend, joining family game night). Many evidence-based treatments for mood incorporate this technique. For example, a brief inventory may reveal that a teen has been withdrawing from social interactions and enjoyable activities, or a significant decrease in such activities. A basic first step is to program an adolescent’s schedule to increase engagement in pleasurable activities. 
What type of activities improve mood?
Preferred hobbies (e.g., music, reading, TV, video games, baking, comedy, photography)
Activities that promote mastery (e.g., sports, skill-based activity, music practice, making something)
Exercise and physical activities (e.g., walking, biking, dancing, sports)
Socializing with others (e.g., talking on phone, hanging out in person)
Helping others and value-oriented activities (e.g., joining a service-oriented club, volunteering)
Pro tip: we feel better when we engage in activities that give us a sense of achievement, connection, or closeness to people/experiences that we enjoy! See additional resources below for some ideas for getting started with behavioral activation.
How do we increase adolescent engagement in positive activities?
  • Make a list of potential activities
  • Create a schedule for good times for each activity
  • Engage in goal setting (e.g., 3 activities/day, several days/week)
Behavioral activation is by nature focused on behavior change. Research on behavioral activation typically involves strategies that increase engagement in adaptive activities to decrease depressive symptoms. Behavioral activation may include the following interventions: activity monitoring, activity scheduling, contingency management, values, and goal setting. The beauty of offering behavioral activation support to our pediatric patients is that it does not require extensive training to maintain fidelity to the model, implement the intervention in different cultural contexts, or to adapt to a range of ages. Parents can easily be incorporated as our therapy partners: by explaining the CBT model, we can enlist parents to help reinforce adolescent engagement in mood-enhancing activities. Unlike the cognitive nuances of other CBT activities (e.g., cognitive restructuring, identifying cognitive distortions), behavioral activation can minimize the need for dealing with abstract reasoning and complex thinking, making it applicable across development.
Perhaps some of us prefer complexity, or are working with older teens who warrant a more cognitive, existential approach. Although the behavioral activation approach is behavioral (e.g., targeting behavioral change), many mindfulness- and acceptance-based interventions incorporate this strategy as well. For example, in dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), we learn about creating a life worth living and living in accordance with our values. In these treatment models, behavioral goal-setting can take on a more value-oriented significance, such that traditional “pleasant event schedules” are filled with personally meaningful moments that assist a teen with remembering their mastery with previously-enjoyed activities, reconsider experiences that have been historically pleasurable, and explore social activities that help reconnect and renew important relationships. In the mindfulness frame, a teen can explore their personal values across many important domains, including family relationships, friendships, education, physical well-being, citizenship, community, and spirituality. Teens with an interest in mindfulness may appreciate encouragement in translating personal values into action and activation. For example, a teen with a passion for social justice may welcome a suggestion to join a local club/group or volunteer opportunities for serving others. An adolescent who values caring friendships may be interested in scheduling time with friends on a regular basis. An athletic youth may consider lifestyle changes to optimize physical fitness.
The persistence of the COVID pandemic will unfortunately continue to contribute to the prevalence of depressive symptoms in children and adolescents (and parents, pediatricians, teachers, nurses, etc!). Our pediatric patients and their families will likely benefit from a mindful dose of behavioral activation to help encourage return to heart-healthy routines that promote mental health.
As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 
855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website ( and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.
Additional Resources

Martin, F., & Oliver, T. (2019). Behavioral activation for children and adolescents: a systematic review of progress and promise. European child & adolescent psychiatry28(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 and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 5345(3), 291–304.
BHIPP Announcements
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BHIPP in Your Neighborhood
  • February 14, 2022 12:30-1:30pm
  • BHIPP Resilience Break: Addressing Picky and Disordered Eating in Young Children within Primary Care presented by Shauna Reinblatt, MD
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  • March 13, 2022 12:30-1:30pm
  • BHIPP Resilience Break: Culturally Responsive, Trauma-Informed Practices for Pediatric Primary Care and Behavioral Health Providers presented by Tiffany Beason, PhD
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

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