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The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
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Core Components
Brief Behavioural Activation for Adolescent Depression (Brief BA) is an intervention which aims to reduce low mood or depression symptoms in young people aged 12 to 18 years. It can also be used as part of a package of care for young people in CAMHS services with more serve depression. Brief BA is delivered by trained practitioners who support young people to increase activities and experiences they value and get enjoyment from. Brief BA draws from the Cognitive Behavioural Therapy model but focuses on changing behaviour as a way to effect cognitions and emotion. Brief BA is a manualised intervention with a delivery model that is practical, based on talking and doing, helping the young person to identify how they are spending their time, identifying what is important to them (their values) and then helping them identify how they could be spending more time doing these things that are important to them. In each session, the young person and the practitioner together pick valued activities/tasks for the young person to complete over the following week in order to help them feel better and more in control of their life, along with specific techniques to practice troubleshooting any problems.
The intervention is suitable for implementation in schools, colleges, communities and health settings and is delivered over six to eight sessions with a review one month after the completion of the 8 th session (sessions 1, 6 & 8 also include an invitation for a parent/carer to participate). The sessions are held in a one-to-one format and are 1- hour in duration.
The eight sessions for young people focus on:
Sessions 1 & 2 - BA Rationale and Activity Log Sessions 3 & 4 - Life Areas, Values and Valued Activities (LAVA) Sessions 5 & 6 - Review of Valued Activities, Contracts and Problem Solving Sessions 7 & 8 - New Areas of Activity, Areas to Work on and Relapse Prevention Finalised with a Review of Progress and Care Plan.
This intervention includes a home-based element encouraging young people to complete a task in advance of each session and completion of a weekly questionnaire. Sessions 1, 6 and 8 includes an invitation to parents/carers. Sharing tasks with parents or carers is also encouraged to help parents understand their child, what is being covered in the sessions and the plans for the week ahead in order that they can offer support and encouragement.
While delivering this programme to young people, risks associated with suicide and self-harm may present. Practitioners manage these risks through individual Safety Plans and through accessing support from their allocated clinical supervisor.
The programme materials and resources include:
A Delivery Workbook ‘Brief Behavioural Activation for Adolescent Depression – A Clinician’s Manual and Session by Session Guide’ which includes all materials required to deliver the programme including well-structured session plans
Data collection materials and routine outcome measures (ROMs) guidance
Young Persons Weekly Activity Logs which includes ratings Achievement, Closeness, Enjoyment, Importance and Daily Mood
Audio/video footage
Workbooks which include at home activities and information sheet for parents/carers
Fidelity
In order to effectively replicate the programme, maintain fidelity and achieve the programme outcomes, all elements of the core programme (content, order and duration of sessions) are to be implemented as described in the Clinician’s Manual. Support to maintain fidelity is provided with the following resources:
Delivery Manual which includes all necessary supporting materials and session checklists Standardised training
Modifiable Components
All core elements of the Brief BA programme should be delivered consistent with the manual. While the programme follows a structured format, therapists can apply flexibility to the session content for example, use problem-solving techniques from session 6, to address issues that arise during the delivery of earlier sessions.
Brief BA can also be offered to young people who are too unwell to engage with Cognitive Behavioural Therapy (CBT), who may be within tier 4 Child and Adolescent Mental Health Services (CAMHS) or in tiers 2 or 3 where but may not be the only intervention offered to the young person and their family.
The developers have also worked with services, and the young people they serve, in other countries and from different cultures to adapt the resources so that they are culturally acceptable to the target population.
Brief Behavioural Activation for Adolescent Depression (Brief BA) was developed by Professor Shirley Reynolds, University of Reading & Dr Laura Pass, University of East Anglia, England.
Support for Organisation/Practice
Implementation Support
Implementation support can be provided by either developer, Shirley Reynolds or Laura Pass. If requested, developers will work with new sites to understand how the intervention can fit within their service and whether modifications will be appropriate for the population they serve. Developers can also offer support to service managers and supervisors to help them think about how the intervention might fit with their systems and existing processes and help them to plan the processes required with regards to referrals, supporting practitioners, supervision structures and managing risk and safeguarding. The manual has suggested weekly routine outcome measures which can be used; however, this is not mandated. The developers can offer support to services to help them think about what data they would like to collect, placing an emphasis on ensuring any regular measures collected are done in collaboration with the young person, that the outcomes are shared with them and that they are being asked at every session about suicide and self-harm.
Licence Requirements
There are no licence requirements.
Start-up Costs
Training can be delivered in person or remotely, for up to 30 practitioners at the cost of £1000 (trainer travel, accommodation etc is not included in this cost). In addition, manuals are required and should be purchased online for around £25 each. Half day supervisor training is an additional £500.
Building Staff Competency
Qualifications Required
No formal qualifications are required to deliver the intervention, however, it is recommended that practitioners should be practitioners from agencies that work with children and young people, for example, school nurses and education staff as well as staff from third sector / charitable organisations. It is important that practitioners have accessed child protection/safeguarding training and have access to regular supervision from a qualified therapist.
Training Requirements
Training is highly recommended and can be accessed through the developers. Training consists of 1½ days of training delivered over 2 sessions. Usually the first day of training is a full day and the second is a half day of training delivered up to 3 months after day one. This gap is to give practitioners a chance to start implementing the intervention before returning for the follow up training session.
In addition, the developers offer a half day training session for supervisors. Potential supervisors can access information and learning about the intervention model through resources available on the British Association for Behavioural and Cognitive Psychotherapies (BABCP) website.
A train the trainer model is available. In consultation with the developers, training resources can be made available for training to be delivered by experienced clinicians. There is no formal training available for trainers.
Supervision Requirements
Regular supervision is strongly recommended. Supervisors are usually qualified therapists with a good understanding of behavioural, learning theory, such as Clinical Psychologist, Associate Psychologists or Cognitive Behavioural Therapists working in Child and Adolescent Mental Health Services. Supervision should be regular, structured, data driven, and skills based. Practitioners are given guidance in the manual about what to expect from supervision, what it should be like and what to take to their supervision session.
Theory of Change
Brief Behavioural Activation for Adolescents (Brief BA) is based on Bandura’s (1977) Social Learning theory and draws from the Cognitive Behavioural Therapy model but focuses on changing behaviour as a way to effect cognitions and emotion. Brief BA for young people has been adapted from the adult model of BA and has been distilled down to focus on changes in behaviour for example, recognising that young people who stop doing things that matter are getting less out of life and less reward which has an impact on their mood. Brief BA supports the idea that a young person’s ability to feel better is strongly connected with how they live their life on a day-to-day basis. This intervention focuses on helping young people develop different patterns of behaviour undertaking valued activities every day to help them break out of a vicious cycle to start to feel better and to increase self-esteem and well-being.
Primary school: 6 to 12 years - Rating: 4+
Research Design & Number of Studies
The best available evidence for Brief BA in children aged 12 comes from one external Randomised Controlled Trial (RCT) and a study undertaken externally to the programme developer. The RCT included adolescents aged 12 – 18 years with a mean age of 14.9 years (n=60) (McCauley et al., 2016) and the second study included young people aged 11-17 years (n=30) (Hodgson, 2019). There was no disaggregated date available in these papers indicating outcomes for 12-year-olds only.
Outcomes Achieved
Child Outcomes
Statistically significant improvement, from pre-treatment to post-treatment, in depression, global functioning, and activation and avoidance. (McCauley et al., 2016).
Significant decrease in depression symptoms and significant increase in functioning symptoms - self and parent reported. (Hodgson, 2019)
Parent Outcomes
Key Reference
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).
Thesis: Hodgson, E.J. (2019). Brief BA for Depression Symptoms in Adolescents: Development of the Brief BA Fidelity Scale, Psychometric Evaluation, and Link to Outcome and Alliance . University of Southampton, Faculty of Social, Human and Mathematical Sciences., PhD Thesis. pp. 1- 100.
Adolescents: 13 to 18 years - Rating: 4+
Research Design & Number of Studies
The best available evidence for Brief BA with children ages 13 – 16 is the same as the evidence above, which includes one external Randomised Controlled Trial (RCT) (McCauley et al., 2016) and a study undertaken externally to the programme developer (Hodgson, 2019) and one additional study which is a pilot study (uncontrolled and unblinded) undertaken by the programme developer which included young people aged 14-16 year (n=20) (Pass et al., 2018).
Outcomes Achieved
Child Outcomes
Statistically significant improvement, from pre-treatment to post-treatment, in depression, global functioning, and activation and avoidance. (McCauley et al., 2016). Significant decrease in depression symptoms and significant increase in functioning symptoms - self and parent reported. (Hodgson, 2019 & Pass et al., 2018)
Parent Outcomes
Key Reference
Thesis: Hodgson, E.J. (2019). Brief BA for Depression Symptoms in Adolescents: Development of the Brief BA Fidelity Scale, Psychometric Evaluation, and Link to Outcome and Alliance . University of Southampton, Faculty of Social, Human and Mathematical Sciences., PhD Thesis. pp. 1- 100.
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).
Pass, L., Lejeuz, C.W., and Reynolds, S. (2018). Brief Behavioural Activation (Brief BA) for Adolescent Depression: A Pilot Study. Behavioural and Cognitive Psychotherapy , 46, pp. 182–194.
Need
Comparable Population
Brief Behavioural Activation for Adolescents (Brief BA) has been developed as an intervention for young people aged 12 – 18 years old who are experiencing low mood or symptoms of depression.
Evidence of the effectiveness of Brief BA includes young people (male and female) between the ages of 11-17 years in schools in England, suffering from low mood or depression and an urban population in the USA with a large proportion of female Non-Hispanic whites.
Is this comparable to the population you serve?
Desired Outcome
Brief BA aims to provide young people with the scaffolding and strategies to improve their low mood, symptoms of depression and day to day functioning. It aims to support young people to identify their values and undertake valued activities every day to help them improve their mood self-esteem and well-being. It is intended to be an accessible, time limited intervention that can be delivered at scale in a range of settings.
Research has demonstrated significant improvements in depression symptoms, day to day functioning symptoms, global functioning, and activation and avoidance.
Is improving low mood, depression symptoms, day to day functioning and well-being in young people a desired outcome for your service?
Need Score
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Fit
Values
Brief Behavioural Activation for Adolescents (Brief BA) draws from the Cognitive Behavioural Therapy (CBT) model but focuses on changing behaviour as a way to effect cognitions and emotion. The premise of the intervention is to get young people to do more that matters to them. The intervention values what is important to the young person at that stage in their life and so is an individualised approach delivered in a structured, manualised way. The approach helps young people identify their values and support them to identify valued activities that practitioners can scaffold and structure. Sessions are active and positive.
Does providing a structured intervention drawing from a CBT model to manage low mood/depression in young people fit with your organisation’s values? Is an intervention focusing on young people’s values and supporting them to do more that matters to them fit with your organisation’s values?
Priorities
Brief BA aims to help young people aged 12-18 years old develop different patterns of behaviour, undertaking valued activities every day to help them break out of a vicious cycle of depression to start to feel better and to improve their self-esteem, well-being, and day to day functioning, in order to get more out of life.
Is supporting young people to do more that matters to them as a way to help them improve their mood and depression symptoms a priority for your organisation?
Existing Initiatives
Does your service already provide intervention programmes aimed at improving young people’s low mood and depression?
Fit Score
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Capacity
One practitioner delivers the intervention individually to one young person. The intervention is delivered over six to eight sessions with a review one month after the completion of the 8 th session. Practitioners attend 1½ days of training and should be practitioners from agencies that work with children and young people. Services delivering the intervention should have a qualified therapist available to offer regular supervision to practitioners.
Do you have appropriate staff available to train? Do you have appropriate staff able to commit time to both training and delivery of the intervention? Do you have qualified therapist available to offer supervision to practitioners?
Technology Support
Internet access and a device is required to access training, if it is being delivered online. In addition, sessions may involve viewing online material with young people.
Do you have the technology available to support viewing online materials and access training?
Administrative Support
Brief BA is typically delivered in schools, colleges, communities and health settings, administrative support may be required to arrange appropriate venues for session. In addition, support for data collection / collation and support for managing referrals may be required.
What setting will the intervention be delivered in? How will appropriate young people for the intervention be identified and referred? Does your organisation have administrative capacity and systems to support the delivery of the intervention?
Financial Support
Initial costs include training of practitioners (£1000 for 30 attendees) and supervisors (£500). In addition, manuals are required for each practitioner (£25).
How many practitioners and supervisors are required to meet your service needs? Do you have finances available to train the required number of practitioners and supervisors? Do you have the finances available to support any indirect costs associated with delivering this programme?
Capacity Score
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