Behavioral Activation for Children

and Adolescents: A Systematic Review

of Progress and Promise (2018)
JOURNAL

Submitted by:
Tamayo, Teanu Jose G. BSN-III D4

In partial Fulfillment of requirement

In CN 109: Duty

Submitted to:
Basat, Rosario Agnes M. RN, MN

July 4, 2018

Supporting articles:

Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-
analysis (2017)
Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis
(2014)
B. SUMMARY

i. Introduction

In summary from what I’ve read, the article recognizes first that adolescent mental health is a global
priority, and from my own research, by the year 2030, depression will be the leading cause of disease burden
globally; in fact, it is already the leading cause of illness and disability in young people (World Health
Organization [WHO, 2013, 2014]). In a large meta-analysis (Costello, Erkanli, & Angold, 2006), the overall
prevalence rates of depression were suggested to be 2.8% for children under 13 years of age and 5.7% for
those aged between 13 and 18 years.

Knowing this, it is important that young people experiencing depressive episodes are identified early
and receive effective treatment to reduce negative symptoms and improve mood. Such treatments may
assist young people to deal with the impact of their depression (i.e., on their family, social, and academic
functioning) and reduce the likelihood or impact of future episodes.

It is described in the article that Cognitive-behavioral therapy (CBT) is recommended for treatment of
children and adolescents, along with interpersonal therapy, psychodynamic therapy, and family therapy..

ii. Gap of the Study and Research Objective

However, access to treatment is low: in the UK, 55% of 12–15 years with mental health problems
receive no service for these needs, and in low- and middle-income countries such as the Philippines, there
are often no or very few available services.

With this in mind, they’re objective was: aimed to explore the scope of studies, current evidence of
effectiveness and how the Behavioral activation has been delivered and adapted, to inform future research.

Behavioral activation (BA) is a third generation behavior therapy for treating depression. It is one of many
functional analytic psychotherapies which are based on a Skinnerian psychological model of behavior
change. It. addressing the lack of positive reinforcement and excess of avoidance behaviors

The behavioral activation model suggests that negative life events such as grief, trauma, daily stressors, or
a genetic predisposition to depression can lead to a person having too little positive reinforcement.
Additionally, a person might turn to unhealthy behaviors--drug use, sleeping late into the afternoon, social
withdrawal, etc.--in an attempt to avoid the negative feelings. These behaviors provide temporary relief,
but ultimately result in more negative outcomes, and worsening depression.

When using behavioral activation, a clinician

intervenes in two primary ways: They increase the
amount of positive reinforcement a person
experiences, and they end negative behavior patterns
that cause depression to worsen. Replacing negative
avoidant behaviors with new rewarding behaviors
increases a person's positive reinforcement and
reduces negative reinforcement.

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 iii. Methods

A systematic review was undertaken searching

PsycInfo, PubMed including Medline, EMBASE, and
Scopus for terms relating to BA and children and
adolescents. Two researchers scored abstracts for inclusion.
Data extraction was completed by one researcher and
checked by another. 19 studies were identified, across 21
published articles. 12 were case studies, with three pre–post
pilot designs and four randomized-controlled trials.

Inclusion limits were: published papers with

participants must include those up to the age of 19 years,
based on the World Health Organization definition of
“adolescence”, and interventions must use BA but not as
part of a broader cognitive-behavioral or other therapeutic
approach. Exclusion criteria were interventions which used
behavioral therapy to reduce problematic behaviors only,
prevention interventions, and purely qualitative papers.

Inclusion flow to the right ->

iv. Results & Findings

It is concluded in the article that, there is evidence for the feasibility of the intervention, and significant
recommendations for how this can be delivered being how it is economically and straightforward in
practice, however there is insufficient evidence to draw conclusions regarding effectiveness, although initial
data support effectiveness for depression. Recommendations for future research include the need to develop
and test BA for young people in low- and middle-income countries (as most studies were made in those
high-income) and with a range of cultures, paying attention to how BA may need to be further adapted for
young people where their social development and role may differ to those in high-income countries.
Methodologically, it is now necessary to move to fully powered RCTs to explore effectiveness in detail.

C. REACTION & DISCUSSION:

1. Insights/Relevance to patients’ care/care

Summarizing points from the journal relevant to patient’s

care:

• Depressed behaviors are seen as a way to cope, largely through

avoidance, which is then directly addressed by engaging in helpful,
alternative coping behaviors. This is backed-up with Skinner’s
theory founded by time tested concepts. Using a specific example
to better exemplify the relevance to patient care, looking at the
situation in the picture, replacing the negative behavior with one of
positivity (maybe with sleeping earlier and waking up earlier) can
affect the whole response and change the cycle of depression.

• As a student nurse doors have been open to an environment more exposed for opportunities to practice
quality improvements in the patient’s care considering the simple intervention of replacing avoidant
behavior with positive feedback can impact care of patients so greatly.

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2. Relevance to area of rotation/local setting/Phil.

Described in the article, that in low- and middle-income countries such as the Philippines, there are
often no or very few available services.

Observed personally, there is a cultural stigma of people with depression. With a common
misconception that depression is simply sadness, and is “not” and “should not” be considered as medical
illness. With BA, it introduces a less intrusive way of intervention for depression conditioning a patient to
do away with avoidant behaviors leading to further depression.

3. Relevance to Nursing Education, Practice and Research

That being said, nursing education and practice aim to find the most effective and efficient way to
deliver holistic care through evidenced based research and practice. Updates such these are massive leaps
towards nursing research, updating practices in dealing with those with depression.

In relation to nursing education, the BA, in my perspective, is a comprehensive step-by-step set of

guidelines and algorithms that can be easily practiced and integrated at any curricula as Skinnerian theory
is already discussed in class. This ensured that in practice, together with the knowledge discussed about the
those with depression, quality and standard are maintained.

4. Learning Insights on the Journal

Reiterating some points stated, significant gains can be made practicing BA. Though there is
insufficient evidence to draw conclusions regarding effectiveness, calling for more fully powered RCT’s to
check the effectiveness, on the basis that it utilizes a well-established theory such as the Operant
Conditioning theory by B.F Skinner, as its foundation, BA as an intervention is a promising treatment to
reduce depression.

References:

Costello, E., Erkanli, A., & Angold, A. (2006). Is there an epidemic of child or adolescent depression? Journal of
Child Psychology and Psychiatry, 47, 1263–1271. doi:10.1111/j.1469-7610.2006. 01682.x

Ekers, D., Webster, L., Straten, A. V., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural Activation for
Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLoS ONE, 9(6).
doi:10.1371/journal.pone.0100100

Martin, F., & Oliver, T. (2018). Behavioral activation for children and adolescents: A systematic review of progress
and promise. European Child & Adolescent Psychiatry. doi:10.1007/s00787-018-1126-z

Tindall, L., Mikocka-Walus, A., Mcmillan, D., Wright, B., Hewitt, C., & Gascoyne, S. (2017). Is behavioural
activation effective in the treatment of depression in young people? A systematic review and meta-analysis.
Psychology and Psychotherapy: Theory, Research and Practice, 90(4), 770-796. doi:10.1111/papt.12121

Ekers, D., Webster, L., Straten, A. V., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural Activation for
Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLoS ONE, 9(6).
doi:10.1371/journal.pone.0100100

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