Behavioural Activation (BA) is a well-established CBT intervention for low mood and depression and is widely used in work with children and young people. Its theoretical rationale — increasing access to positive reinforcement through engagement in meaningful activity — is well supported within the adult literature and increasingly within adolescent samples (Pass & Reynolds, 2017; Pass et al., 2018).
However, translating BA into effective, developmentally appropriate practice with young people is not always straightforward. Clinicians frequently report challenges that are less about adherence to the model and more about the interaction between depressive symptoms, developmental stage, and contextual constraint.
This blog explores five common clinical challenges encountered when using BA with young people, drawing on emerging research alongside clinical experience, and considers implications for formulation-led practice.
1. Difficulty Translating Intentions Into Action
Young people may engage thoughtfully in sessions, articulate clear goals, and express motivation, yet still struggle to initiate or complete agreed activities between sessions.
Research suggests that adolescent depression may be associated with difficulties in executive functioning, including working memory, planning, and initiation (Gillespie et al., 2022; Schumacher et al., 2024). During periods of low mood, tasks that require holding plans in mind, sequencing steps, and getting started may therefore place increased cognitive demands on young people, even when motivation appears intact.
From this perspective, non-completion of activities may reflect cognitive and developmental constraints rather than lack of engagement or willingness.
Clinical considerations
Clinicians might consider conceptualising initiation as a therapeutic focus in its own right, rather than assuming it will naturally follow from insight or motivation (Reynolds & Pass, 2017).
It may be helpful to reduce cognitive load by simplifying plans, externalising reminders, or agreeing only the first actionable step of an activity, rather than the full task.
When activities are not completed, clinicians may find it useful to explore collaboratively where the process became difficult, rather than framing the difficulty in terms of why the task was “not done”, supporting problem solving without increasing self-criticism.
2. Limited Reinforcement Despite Increased Activity
Even when activities are completed, clinicians often observe that they do not reliably lead to immediate improvements in mood or pleasure. Young people may describe activities as effortful, emotionally flat, or neutral.
Developmental research indicates that reward processing continues to mature throughout adolescence and may be further blunted in depression, limiting the extent to which positive experiences are registered or consolidated (Luking et al., 2016; Watson et al., 2021). As a result, behavioural change may precede — rather than coincide with — subjective changes in mood.
This has important implications for how BA is reviewed and evaluated within sessions.
Clinical considerations
Clinicians might consider shifting review questions away from “Did that improve your mood?” towards prompts such as “What did you notice?” or “What did this tell us about how your mood is working at the moment?”
Normalising limited reinforcement early in treatment may help position BA as a process of information-gathering and learning, rather than a direct or immediate mood-fixing strategy (Reynolds & Pass, 2017).
Attention may also be given to non-hedonic outcomes, such as effort, agency, or disruption of avoidance patterns, particularly when pleasure remains muted (Watson et al., 2021).
3. Heightened Sensitivity to Setbacks and Perceived Failure
When activities do not go as planned, young people with low mood may respond with increased self-criticism, withdrawal, or disengagement from therapy tasks altogether.
Adolescent depression is associated with negative self-evaluative processing and a tendency towards global, stable self-judgements in response to setbacks (Hards et al., 2020; Orchard et al., 2019). Without careful handling, BA tasks that are framed too evaluatively may inadvertently reinforce beliefs about incompetence or hopelessness.
Clinical considerations
Clinicians may find it helpful to review difficulties using a collaborative, problem-solving framework rather than evaluative language.
Explicitly separating effort from outcome may support young people to recognise engagement without equating outcomes with personal failure.
Modelling curiosity and flexibility when plans need to change can reinforce the idea that adaptation is expected within therapy, rather than a sign of failure or inadequacy.
4. Constraints on Autonomy and Choice
Unlike adults, young people often have limited control over their time, resources, and environment. School demands, family routines, financial dependence, and parental expectations shape what is realistically achievable.
Qualitative research highlights that young people’s engagement in therapy is strongly influenced by whether interventions feel feasible within their real-world context and whether their perspective is meaningfully incorporated into planning (Kitchen et al., 2023).
BA plans that do not sufficiently account for these constraints may inadvertently increase disengagement.
Clinical considerations
Clinicians might consider anchoring BA planning closely to contextual formulation, rather than abstract values or idealised activity goals.
Where external constraints are present, it may be helpful to clarify what the young person needs the activity to provide (e.g. structure, social contact, a sense of competence), rather than focusing solely on the activity itself. This can support greater flexibility in identifying feasible alternatives that meet the same therapeutic function.
5. Behavioural Activation Becoming Experienced as Pressure
When BA is experienced as another expectation or demand, it may increase avoidance rather than reduce it, particularly for young people who already feel overwhelmed or inadequate.
Qualitative findings suggest that young people value therapy that feels collaborative, flexible, and responsive. Even well-intended structure may feel pressurising if it is not sufficiently attuned to emotional and cognitive capacity at a given point in treatment (Kitchen et al., 2023).
Clinical considerations
Clinicians may find it helpful to attend to the emotional meaning BA tasks take on for the young person, particularly if engagement begins to reduce.
Framing activities as experiments to notice what happens, rather than tasks to be completed successfully, may help reduce pressure and support curiosity, especially during periods of heightened stress or symptom severity.
Problem Solving as Central, Not Adjunctive
Taken together, these challenges suggest that problem solving is not an optional add-on to BA, but a central therapeutic process when working with young people experiencing low mood (Reynolds & Pass, 2017).
From a CBT perspective, this involves:
- Making obstacles explicit rather than implicit
- Actively exploring what interferes with action and reinforcement
- Supporting young people to adapt plans without self-blame
- Ensuring tasks remain proportionate to cognitive and emotional capacity
Importantly, this represents a developmentally informed application of BA, rather than a departure from its core principles.
Concluding Thoughts
For experienced clinicians, difficulties with BA are rarely a matter of poor implementation. More often, they reflect the complex interaction between depressive symptoms, developmental stage, and environmental constraint.
Attending closely to problem solving, context, and the young person’s experience of tasks may help BA remain therapeutically active rather than procedurally driven, particularly when progress is slow or reinforcement is limited.
As the evidence base continues to develop, qualitative research offers valuable insight into how young people experience our interventions, and where thoughtful flexibility may support engagement and retention (Kitchen et al., 2023).
References & Further Reading
Gillespie, C. F., Porter, K., & Birmaher, B. (2022). Executive functioning in adolescents with major depressive disorder: A systematic review and meta-analysis. Frontiers in Psychiatry, 13, 973726. https://doi.org/10.3389/fpsyt.2022.973726
Hards, E., Loades, M., Higson-Sweeney, N., Shafran, R., & Reynolds, S. (2020). Negative self-cognitions and emotional symptoms in young people: A systematic review and meta-analysis. Journal of Affective Disorders, 272, 747–759. https://doi.org/10.1016/j.jad.2020.03.115
Kitchen, C. E. W., et al. (2021). Behavioural activation for depressed adolescents: A feasibility randomised controlled trial. Behavioural and Cognitive Psychotherapy, 49(2), 135–151. https://doi.org/10.1017/S135246582000057X
Kitchen, C. E. W., et al. (2023). Barriers and enablers for young people, parents and therapists undertaking psychological therapy for depression: A qualitative study. Psychology and Psychotherapy: Theory, Research and Practice, 96(3), 730–748. https://doi.org/10.1111/papt.12458
Luking, K. R., Pagliaccio, D., Luby, J. L., & Barch, D. M. (2016). Depression risk predicts blunted neural responses to gains and enhanced responses to losses in healthy children. Journal of the American Academy of Child & Adolescent Psychiatry, 55(4), 328–337. https://doi.org/10.1016/j.jaac.2016.01.011
Orchard, F., Pass, L., Marshall, T., & Reynolds, S. (2019). Clinical characteristics of adolescents referred for treatment of depressive disorders. Clinical Child Psychology and Psychiatry, 24(1), 3–17. https://doi.org/10.1177/1359104518792259
Pass, L., & Reynolds, S. (2017). Behavioural activation for adolescent depression: A pilot study. Behavioural and Cognitive Psychotherapy, 45(1), 1–14. https://doi.org/10.1017/S1352465816000450
Pass, L., Whitney, H., & Reynolds, S. (2018). Brief behavioural activation for adolescent depression: A pilot study. Behavioural and Cognitive Psychotherapy, 46(2), 182–197. https://doi.org/10.1017/S1352465817000602
Schumacher, L. M., Thomas, A. J., & Kaiser, S. (2024). Cognitive functioning in adolescent depression: A meta-analytic review. Psychiatry Research, 333, 115395. https://doi.org/10.1016/j.psychres.2023.115395
Watson, J., Pass, L., & Reynolds, S. (2021). Adolescents’ experiences of behavioural activation for depression: A qualitative study. Behavioural and Cognitive Psychotherapy, 49(5), 556–571. https://doi.org/10.1017/S1352465821000235