Some simple steps to using principles from Behavioural Activation to improve the mood of Children and Families who are at home and self-isolating

Dr Andrew Beck
BABCP President-Elect ELCAS (East Lancs Child and Adolescent Service)

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Children and families have been managing self-isolation for over a month now and this is likely to continue in one form or another for the foreseeable future. One of the challenges they will face is how to spend time at home in a way that maintains a good mood and which does not increase feelings of sadness, isolation and a sense of lacking a purpose. This can make depression worse in people who are already struggling and lead to low mood in people who might be vulnerable. In this short article we are going to look at how an evidence based treatment for depression called Behavioural Activation (BA) could be helpful.

Dr Jo Daniels of Bath University has already written about how Cognitive Behaviour Therapy can provide a useful framework for managing some of the understandable worries that the pandemic are likely to lead to and OCD-UK have written some advice for people struggling with Obsessive Compulsive Disorder who might be struggling to tell the difference between symptoms of OCD and the very real need to improve hygiene to reduce risks to themselves and their families.

What is Behavioural Activation?

Behavioural Activation is based on a simple idea. We feel better when we do activities that provide us with a sense of Achievement, Connection or Closeness to others or which we Enjoy (often called ACE activities, see below). Depression or low mood make it less likely that we will do the activities that make us feel good. When this happens we end up in a vicious cycle where we do less activities that are good for us, so we feel worse emotionally and physically, and because we feel worse we are less likely to do these helpful activities.

Research into treating depression shows us that a day that includes a good balance of ACE activities is one that will lead us to have a better mood. These principles are true across the lifespan and are as important for children as they are for older adults.

ACE activities

Every activity we do can be scored according to how ACE it is.

For example a basked full of freshly washed clothes provides an opportunity for an ACE activity and someone might score sorting out and folding the clothes as:

  • Achievement 6/10 (it feels good to get it done)
  • Closeness 1/10 (as done alone)
  • Enjoyment 4/10 (pleasant enough)

A task can be improved by doing it a little differently. For example doing it with a family member  and listening to music together might then rank it:

  • Achievement 6/10 (the same as before)
  • Closeness 6/10 (as there is a chance for conversation)
  • Enjoyment 6/10 (it is a little more enjoyable as the task takes less time and is done better)

Example two: Playing a board game together as a family might be ranked differently by different family members so for one parent it might score:

  • Achievement 2/10 (it just passes the time, nothing is achieved)
  • Closeness 9/10 (enjoyable time spent with children)
  • Enjoyment 6/10 (quite good fun)

But a reluctant child who does not particularly like that game might score it:

  • Achievement 1/10 (a waste of time)
  • Closeness 4/10 (okay spending time with a parent)
  • Enjoyment 4/10 (okay but not great)

Which might be better than some alternative activities but might not be the way that they would most like to spend their time at home.

This means that activities involving family members are better negotiated to make sure that everyone gets activities during the day that have a good mix of ACE scores. Some activities might just need doing (like tidying a room) and these might score quite low on all three points for everyone but where this needs to be done it can be followed by an activity that scores higher for everyone to give a sense of reward for getting things done.

Helping a family plan time together

A useful way to start planning a week as a family is to write down a list of activities and get everyone to work together to score them using the ACE framework. This will give everyone a good idea of how people might want to spend their time and give families a chance to get a good balance of activities. Writing down a long list of things you might want to do is a good way to start. It can include ambitious tasks like rearranging a bedroom and simple tasks like reading or watching television or something in between like trying a new recipe or baking a cake. It should also include social activities like calling friends and family.

Activities should have a good balance of practical, social and enjoyable activities and families should be taken to include physical activities even if this is limited to things like skipping for 10 minutes or doing an online exercise routine.

Planning 2-3 days at a time is probably the best approach. Some of the parents we are working with are likely to be really struggling at the moment and it might be that just planning one ACE activity a day at a time is as much as they can manage initially. Wall calendars are likely to be too small to plan properly so at the end of this article there is a link to a website where you can download a sample BA diary planner.

We would suggest starting a planned day with agreed times to get up. It is tempting to start lying in and staying up late when there is no school or work to provide a clear structure. Disrupted sleep patterns can have quite a negative impact on people’s mental health and general health and physical well-being so we would suggest that these times are kept as close to what they would typically be as possible. The same principle goes for mealtimes. Try to help families plan for most parts of the day. If the activity planned is just a 10 or 15 minute one (such as run up and down stairs until you are out of breath) that is fine. There is no harm in having time to just relax in an unstructured way.

Try to look at the balance of activities. If there is a whole morning that is high on scores for Achievement but low on Closeness and Enjoyment make sure that families catch up on these later in the day.

Planning things out in advance has a number of advantages. It lets people see the general shape of the days and week ahead in advance so that you can make adjustments to keep it well balanced. You can also think about whether the activities reflect the values and interests of everyone involved. If helping others is important make sure that time includes activities for that. If learning new things is important make sure that there is time for that. Parents may have work responsibilities so structure those in and do the same for homework time.

Sticking to plans

It is important that families stick to the plans they make together. One of the hardest things about using Behavioural Activation for depression is the tendency that people have to do what they feel like rather than what they have committed to. Low mood generally makes us feel like not doing very much and it is tempting to abandon more effortful activities (like a family game of table tennis that might be 8/10 for Achievement, 7/10 for Closeness and 5/10 for Enjoyment) in favour of a less effortful one such as watching television in relative silence (1/10 Achievement, 3/10 Closeness, 6/10 Enjoyment).

One principle we use in BA for treating depression is the idea that you plan in advance and act according to the plan not according to mood and we think this same principle will be useful for people who are self-isolating. If there are times when it is hard to act according to your plans it is worth stopping and thinking about what might be getting in the way. It could be feelings associated with becoming physically unwell are making it hard to get started, in which case it might be necessary to step things down a little and do something less effortful. It might also be that thoughts about the pointlessness of the activity might be making it hard to get started. Where this is the case we have found that just committing to doing the activity for a short time may be enough to get started. For example the plan might have been to totally clear out and clean a storage area, this might be an hour long task, telling yourself you will do it for a shorter amount of time like 10 minutes and then reviewing how you are getting on might give an opportunity to see if you can do more or if you need to substitute for a different activity.

Screen time, phones and watching TV

One pressure people might struggle with is managing screen time, and mobile phone use especially. Different members of the household might have different views on how much time should be spent on phones and social media during a time of isolation. It might be worthwhile talking this through and setting some limits and expectations for everyone. Screen time can be built into the day as part of planned activities and agreements made about different uses of screens. For example time on a screen doing homework would count differently to time on social media or watching Youtube. It might be a good time to download apps that allow screen time to be monitored if this hasn’t already been done. Screen time itself is not a bad thing. It is just that most screen based activities are unlikely to score very high on any of the ACEs and that time on a screen is time not spent on other activities that might be better for people’s mood and well-being.

It is likely that family members will have commitments to do with remote working or studies and time for these should also be built into the day but it is important to remember that most jobs and time in education generally involve some welcome social contacts to it will be important to make sure that periods of work or study are followed by enjoyable and preferably social activities.

Families can discuss how activities went to help plan future activities and get a better sense of what works for everyone.

We know that one way to boost happiness is to do something for others. This can be for immediate family members if you are not in a position to leave the house or for friends and neighbours. Building in activities such as baking for an elderly neighbour and taking it to their home is likely to score high on ACEs for you and help their mood too though bear in mind the need to balance this with the need to reduce social contacts and the chances of spreading infection to people who are vulnerable.

What looks like a challenging time ahead might lead to opportunities for new experiences and activities or for things that there is normally not enough time for. The more individuals and families look for opportunities to be closer and more engaged with one another the better the time will seem.

Helpful Resources

Worksheet for deciding on some ACE activities to do

This worksheet then links to diaries and other resources you can use.

These include an ACE log and a weekly planner

Conflict of interest statement: No conflicts declared.

Discussion

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Article in simple and easy to understand format for professionals and others to relate.
Worksheets and ACE log provided would be practically useful .

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