Chapter 10

ACT with Children,

Adolescents, and Their
Parents
AMY R. MURRELL, LISA W. COYNE,
AND KELLY G. WILSON

In contrast to the growing empirical support for ACT interventions with

adult problems and populations, ACT applications with children, ado-
lescents, and their parents are in relatively early stages of development.
Our preliminary data, and data from other sites, suggest that ACT and its
components can be successfully adapted for children in developmentally
appropriate, therapeutically beneficial ways. Evidence suggests that ACT
can be useful to parents dealing with the challenges children present. As
with any new intervention, conceptualizing and using this approach is a
trial-and-error process. Keeping this in mind, clinicians using the adapta-
tions suggested in this chapter should be committed to measuring progress
through the use of ongoing assessments.

ASSESSMENT AND CASE CONCEPTUALIZATION

The ACT formulation of suffering and distress for children is really no

different than it is with adults, but the form it takes and the complexity of
the child's context can be different. The key variables in the equation are
the excessive use of emotional control! avoidance strategies, based upon
cognitive fusion with unpleasant content, and the child's resulting inability

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250 Amy R. Murrell et al.

to pursue valued life directions in the arenas of family, friends, recreation,

studies and so forth. Particularly with children, a competent ACT case
conceptualization assessment always begins with a functional analysis of
the problem behaviors that bring the child to treatment in the first place.
From a contextual point of view, it is very important that you the therapist
understand the factors that are related to the appearance of problematic be-
haviors, as well as both internal and external "reinforcements" that might
maintain those behaviors.
From an ACT perspective, the key factors to look for are the degree of
experiential avoidance evident in a problematic behavior pattern as well
as restrictions in valued life outcomes that are the result of such avoidance.
Very frequently, we find that children spend a great deal of time engaged
in experiential avoidance in attempts to reduce or control suffering that
is often triggered by fusion with beliefs or expectancies. In children these
efforts are often overt and behavioral, such as avoiding school or failing to
perform tasks. While such efforts may eliminate painful events in the short-
term, they undermine behaviors that will lead them in more meaningful,
valued directions. Thus, ACT case conceptualization with children tends
to focus on the following core areas:

1. The form, frequency and intensity of the problematic behavior

2. The situational triggers for these behaviors, both internal private
experiences and external events
3. The distressing thoughts, feelings, memories, sensations or events
that the problematic behavior pattern is helping the child avoid
4. The specific experiential avoidance/ control strategies used to man-
age painful psychological content
5. The short-term reinforcers (e.g., feeling less anxious, feeling more
accepted) that maintain these unworkable control strategies
6. An assessment of the client's valued directions in school, recreation,
friendships, family, etc.
7. The extent to which problematic behaviors are interfering with any
or all of these desired life outcomes.

For example, an ll-year-old boy was referred to a clinic for school re-
fusal behavior. Presenting symptoms included pervasive worry, irritability,
and somatic concerns; he was given a provisional diagnosis of Generalized
Anxiety disorder. During the functional analysis interview, the child stated
that, "being called a mama's boy shows up when I think about going to
school". Once this painful content was identified, the therapist and client
listed all the things the client did to avoid going to school. Working with
children normally requires seeking information from the parents (and sib-
lings if available), because the family unit forms an extremely important