Act Com Crianças Recursos

ACT for Treating Children The ACT Kidf lex
The ACT Kidflex
Stay Here
Let It Be Choose What

Matters
I Am Flexible
Let It Go Do What
Matters
Notice Yourself
(Adapted from Hayes et al., 2006)
1
ACT for Treating Children Extended Case Protocol: Sally, Eight Years Old
Extended Case Protocol: Sally, Eight Years Old
In ACT for Treating Children, we looked at the ACT Kidflex and its six processes (let it be, let it go, choose what matters, do what
matters, stay here, and notice yourself), as well as self-compassion, which I call be kind and caring to yourself. Now, I’ll introduce
you to the case example of Sally, who was afraid to attend school following an argument on the school playground with another
student.
Overview of Sally’s Treatment

Sally attended six therapy sessions. We will go through each session one at a time, and you’ll see from start to finish how you
can treat children using the ACT Kidflex together with be kind and caring to yourself. I’ll first provide a table outlining all of
the sessions, including the processes addressed, exercises conducted, and recommended home tasks for both Sally and her
parents. Then, I’ll go through each session in greater detail.
OVERVIEW OF SESSIONS WITH SALLY
Session Description Exercises Home Tasks
One Case Conceptualization and Case conceptualization template Let your thoughts and feelings be
History Taking; without doing anything with them
Don’t Think About Chocolate Cake
Let It Be
Two Let It Be and Let It Go Saying Hello to our Thoughts and Say, “I’m having the thought that…”
Feelings
Play with friends or go to the school
“I’m Having the Thought That…” playground even when worried
Blowing Bubbles Parents to model “I’m having the
thought that…” to Sally
Worksheet: Letting Our Thoughts Be
Three Choose What Matters and Do Think about a time when you did what Think about what matters to you about
What Matters mattered to you playing on the playground
Magic Wand Question Worksheet: Go to the playground even when your
Magic Wand mind worries
Parents to model choosing what matters
and doing what matters to Sally
2 © 2022 Tamar D. Black / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
Session Description Exercises Home Tasks
Four Stay Here and Notice Yourself Listening to Music While Staying Here Practice staying here and noticing
yourself at school and home
Watching a Movie of Your Life
Eating dinner while staying here exercise
Worksheet: Watching a Movie of Your
Life Parents to model staying here and
noticing themselves to Sally
Five Be Kind and Caring to Yourself Imagine a Kind and Caring Friend Read the kind and caring letter at home
and create a mini-version to read at
Write a Kind and Caring Letter to
school
Yourself
Use kind and caring language at school
and home for difficulties and successes
Parents to model using kind and caring
language to Sally
Six Let It Go Singing Our Thoughts Review worksheets as needed

Review Review of strategies
Let’s look now at each session with Sally in greater detail. Her parents, Ann and Bill, attended the first session with Sally,
and after that Ann attended sessions with Sally.
Session One: Case Conceptualization, History Taking, and Let It Be

I began the first session by asking Sally and her parents questions about her problems, difficulties, and history using the
ACT case conceptualization template (see chapter 2 for more details; this can be downloaded from the New Harbinger
website, http://www.newharbinger.com/49760). Sally was in third grade and had been fearful of attending school for a few
weeks since having had an argument on the playground with another student. The other student, Kendra, had apologized to
her, but Sally was still highly anxious about going to school and was worried that Kendra might say something unkind to her.
On weekdays before school, Sally frequently complained of stomach pain in an attempt to avoid going to school. When she did
attend school, she often experienced stomach pain, especially right before recess and lunch, and spent a lot of time in the
school nurse’s office as a result.
Through developing a case conceptualization with Sally and her parents, I learned that Ann and Bill were trying very hard
to help Sally reduce her anxiety using distraction (by suggesting that Sally watch television, play a game, or read) when she felt
anxious or scared about going to school. While it was clear that the purpose of this was to try to help Sally, distraction and
trying not to think of something are not consistent with the aim of the ACT Kidflex, I am flexible.
I asked Sally whether these techniques were helpful, and she stated, “No matter how much I try to keep busy, or think
about other stuff, I still think of school, and how scared I am of having another argument with Kendra.” As a result, I didn’t
need to introduce Sally to creative hopelessness (an acknowledgment by the child that what they have been doing to try to
control or avoid the problem or difficulty, in order to try to manage it, has not been working; see chapter 2 for further detail),
as she was acknowledging that her efforts to try to control her thoughts weren’t working.

HELPFUL HINT
If you are working with a child who tells you that their efforts to control or avoid their problem or difficulty—such as distracting
themself or not going to school—are working for them, or sometimes work, I recommend that you introduce creative hopelessness
by asking some questions about whether what they are doing helps them (see chapter 2 for further detail). After this, you could
try using the metaphor Needing the Restroom During a Movie (see chapter 2), which I find works really well for children aged five
to twelve years, as well as their parents, as it’s something that’s easy for most children to imagine and is also quite engaging. I also
find that this metaphor can be really helpful for building rapport with children because they often find it quite funny.
After developing my case conceptualization and hearing Sally’s history, I suggested to Ann and Bill that when Sally see me
for therapy sessions, they join us for part of each session (or all of the session if Sally would like that). I explained that I would
give them feedback about the strategies I was teaching Sally, and I would also train them in the ACT Kidflex in order to teach
them some new techniques for responding to Sally when she’s anxious and reluctant to attend school. Sally said that she
thought this was a good idea and was happy for her parents to join us for the whole of the sessions. Ann and Bill were very
pleased with this idea and stated that they were keen to learn any new techniques that might be helpful for Sally, not just
related to her anxiety about school, but also to help her with other possible issues in the future.
In response, I explained that I would invite Ann and Bill to also participate in some of the exercises in Sally’s therapy ses-
sions alongside her, so they could learn firsthand how to use the techniques in order to remind Sally how she could practice
using them. I also mentioned that if they found the ACT Kidflex techniques helpful themselves, they might also like to start
using them in their own lives (which might increase the likelihood of them encouraging and reminding Sally to use them).
I wanted to teach Sally something she could start using to manage her anxiety right away, and because she was trying to
avoid attending school, I felt that introducing her to the ACT Kidflex let it be process was the greatest priority. In response, I
invited Sally to take part in the Don’t Think About Chocolate Cake exercise (Hayes et al., 1999; see chapter 3 for more detail),
which she was happy to do (I find that children are often very willing and also curious to try this after hearing the title), and
her parents participated too.
Sally had no difficulty imagining chocolate cake, and she responded with lots of giggles, telling me that she couldn’t stop
thinking about chocolate cake. Ann and Bill said that they weren’t able to not think of chocolate cake either. I found that this
was a really nice way to end the first session with Sally (as well as her parents). It also helped me start to develop rapport with
Sally, who had looked nervous at the start of the session, likely because she hadn’t met me before or attended the clinic before
and didn’t know what to expect.
Then, I let Sally know that her thoughts of being worried about having an argument with Kendra could not actually harm
her. I suggested that she try to let her feelings be, at home and at school, by letting let her mind come up with whatever
thoughts it wanted to, without trying to get rid of them or do anything else with them—she could just allow them to be there.
Then I recommended to Ann and Bill that instead of trying to distract Sally when she’s anxious or afraid of going to school,
they could reassure her that her thoughts and feelings of being afraid and not wanting to go to school can’t harm her, and they
could encourage her to let her thoughts be.
Session Two: Let It Be and Let It Go

It was clear in the first session that Sally’s thoughts of being afraid to attend school had a lot of power over her—she
believed everything her mind told her. This was confirmed when Ann told me at the start of the second session that it had been
a few weeks since Sally had gone onto the school playground, due to her fear of seeing Kendra, the student she had the argu-
ment with. As a result, in this session I continued with the ACT Kidflex process let it be and also introduced Sally to let it go

to empower her and give her tools so that she could go to the playground, rather than believing everything her mind told her
and being controlled by her thoughts.
I invited Sally to participate in the let it be exercise Saying Hello to Our Thoughts and Feelings (see chapter 3 for further
detail). I suggested that when worries show up, she try saying hello to her thoughts and feelings, for example, “Hello being
worried to play on the playground, it’s nice to see you.” I let Sally know that she could also imagine giving her thoughts and
feelings a pat on the shoulder (Twohig, 2014). I invited Sally to think about the thoughts and feelings that show up when she’s
afraid to go to school, or afraid at school to go to the playground, and say hello aloud, followed by saying her thoughts and
feelings. We each took turns saying hello to our thoughts and feelings aloud, followed by saying the thought and feeling, and
we had fun doing this.
HELPFUL HINT
When sharing thoughts and feelings with children, I recommend that you use fairly neutral thoughts that are appropriate for
sharing; see chapter 1 for further detail.
Then, to teach Sally let it go, we went outside for a bubble blowing exercise (I find that going outside for this exercise works
well as children usually enjoy watching the bubbles blow in the wind, but if you can’t go outside, you can do this exercise
indoors). We each took turns saying aloud, “I’m having the thought that…” followed by saying a thought (see chapter 3). Then,
we blew bubbles without doing anything to try to get rid of the bubbles (see chapter 3). I suggested to Sally that when she thinks
about school, or anything else that her mind worries about, she could try saying, “I’m having the thought that…” followed by
the thought.
You might have noticed that I used the phrase “her mind worries about”—this is a quick and simple let it go phrase that
Sally could use to manage her thoughts about being afraid or worried so that her thoughts have less control over her, which
will help her to go to school, even when her mind worries.
Some of the thoughts Sally expressed were lighthearted (for example, “I’m having the thought that I wonder what I’m
going to eat at lunch today before playing with my friends”), while some were associated with her fear of seeing Kendra (for
example, “I’m having the thought that I’m scared she might say something mean to me”). While Sally was having fun blowing
bubbles, I explained, “Just as we can notice the bubbles without trying to do anything to get rid of them, we can also notice all
the thoughts our mind comes up with. Our thoughts can’t hurt us, and we don’t have to try to do anything with them—we
can just let them be.”
After doing this exercise, we returned to the consulting room and had a brief discussion about the exercise. I asked Sally
what it was like doing the exercise and what she noticed, and she said that her thoughts didn’t worry her nearly as much as
they had before we did the exercise. I also asked her to think about situations she could try using the phrase “I’m having the
thought that…” and whether she’d be willing to try saying to herself, I’m having the thought that… when she was worried about
seeing Kendra or worried about playing in the playground. Then, she could play with her friends or go to the playground even
if her mind was having the thought that she was worried. Sally said she’d like to try that.
Each time I talked to Sally about her thoughts, I used phrases like “your mind was having the thought,” “your mind
worries” and “your mind came up with,” which teaches Sally to let it go. I purposely used these phrases in the hope that the
more I reminded her of how to use let it go, the greater the likelihood that she would remember these phrases after our session
and would start to use them herself.

Toward the end of this session, I invited Sally to complete the worksheet Letting Our Thoughts Be (see chapter 3 for
further detail; this worksheet can be downloaded in color from http://www.newharbinger.com/49760). After completing it,
Sally took it home as a reminder of what she had learned in this session.
At the end of this session, I recommended to Sally that she try practice saying, I’m having the thought that… for everyday
thoughts, such as I’m having the thought that I’m hungry, or I’m having the thought that I’m thirsty, or I’m having the thought that I’m
tired, or I’m having the thought that I need the restroom. I recommended to Ann that she and Bill also practice saying “I’m having
the thought that…” aloud in front of Sally ideally once a day, for everyday, neutral thoughts, to increase the likelihood that
Sally will start to do this herself for her own thoughts. Then, I recommended that they carry out the thought in order to teach
Sally that her thoughts don’t have to stop her from doing things. For example, Ann or Bill could say aloud, “I’m having the
thought that I’m worried this new recipe won’t turn out great,” then cook the new recipe anyway. This way, her parents will be
modeling to Sally how to use this phrase, which will remind Sally to use it and show her how to use this phrase for everyday
thoughts. This may increase Sally’s likelihood of using this phrase herself, as opposed to if she only hears it in therapy
sessions.
I explained to Ann that the aim of regularly modeling this let it go phrase to Sally was so that she would hopefully start
going to the school playground even when her mind tells her that she’s worried about seeing Kendra. I also recommended to
Ann that she and Bill encourage Sally to play on the school playground with her friends even if she feels scared, and remind
her that her thoughts can’t hurt her and don’t have to stop her from enjoying herself at school, which also reinforces the recom-
mendations I provided in session one.
Session Three: Choose What Matters and Do What Matters

At the start of this session, Ann told me that Sally was far less anxious and much happier, and she was attending school
each day without any reluctance. Sally informed me very excitedly that after our last session, she had played on the playground
at school. She reported that she felt nervous but wanted to have fun with her friends, so she kept playing. This was great prog-
ress, and I gave Sally lots of positive reinforcement, telling her that she had done a great job not letting her thoughts of feeling
afraid stop her from playing on the playground.
I continued to model the let it go process I had taught Sally in the last session by using phrases such as “not letting your
thoughts of feeling afraid stop you.”
In this session, I introduced Sally to choose what matters and do what matters because after teaching Sally to let it be and
let it go in the previous session, I hoped that learning about choose what matters and do what matters would teach her how to
do the things that mattered to her, instead of using avoidance to cope with her thoughts and feelings.
You might be wondering why I still wanted to teach Sally about choose what matters and do what matters when she had
already played on the playground prior to this session. It was important to increase Sally’s resilience so she could go to school—
even when her mind came up with thoughts of being afraid— and continue to play on the playground even if her mind told
her she was worried about seeing Kendra. Teaching children to choose what matters and do what matters is a really powerful
and effective way to help them become more resilient.
To start introducing Sally to choose what matters and do what matters, I asked her to think of other situations, apart from
school, where she had done something that mattered to her, even though her mind had told her she was nervous, scared, or
afraid. Sally recalled having been scared to go on a roller coaster at the amusement part, but went anyway, because she thought
it would be fun, and she didn’t want to miss out on going on the roller coaster with her older sister and parents. I emphasized
that we can do things that are safe (like going on a roller coaster, and not like crossing the road without using the crosswalk),
even if we feel scared, so that we don’t miss out on things that are important to us (see chapter 2 for further detail about
emphasizing talking to children about safe things).

Then I asked Sally, “Are your thoughts and feelings stopping you from doing anything at school that matters to you, or
elsewhere?” (see chapter 4 for further detail). She replied that she wanted to have fun at school with her friends at recess, but
sometimes she avoided going to the playground because she was worried that Kendra would be mean to her. Sally noted that
she went to the school nurse’s office a lot because her thoughts about the argument and worries about seeing Kendra made her
stomach ache, but that she would rather spend recess and lunch playing and having fun instead of visiting the nurse’s office.
To help Sally identify what she might do at school instead of trying to avoid the playground, I asked her, “If I had a magic
wand that could help you cope with your thoughts and feelings of being worried about Kendra, what might you start doing that
really matters to you, or what might you start doing more often?” (See chapters 2 and 4 for further detail). Sally replied that
she wanted to enjoy school and was missing out on having fun on the playground. She wanted to play with her friends, and
also make new friends.
I invited Sally to write these things down on the Magic Wand worksheet so that she would be able to look at it at home
and remember what she had learned. Sally agreed to complete the worksheet, and she drew a magic wand and decorated it
with glitter (see chapter 4 for further detail; you can download this worksheet in color from http://www.newharbinger.
com/49760). Sally took the worksheet home with her, and I suggested she might like to put it on the wall in her bedroom.
Then, I asked Sally, “What are some small things that you can start doing at school that matter to you, even if your mind tells
you that you are worried or afraid?” (See chapter 4 for further detail.) The reason that I added “at school” was to keep the
discussion specific to school—asking, “What are some small things that you can start doing that matter to you?” would be too
vague for an eight-year-old, and she probably wouldn’t link the question to the reason she was seeing me.
I recommended to Sally that when she’s at school, she think about what matters to her about playing on the playground,
then go to the playground at recess and lunch, even if her mind tells her that she’s worried about Kendra. In this way, Sally
would be choosing and doing what matters to her. Then, I asked Sally if she would be comfortable with her mom letting the
teacher know that Sally was fearful of going to the playground, which she said she was. In response, I suggested to Ann that
she ask the teacher if they could conduct a class activity on the playground, or perhaps take the class to the playground during
free time, and, if Sally was reluctant to join in, reassure her that she’d be safe. The reason for suggesting time on the playground
was to use exposure (this refers to safely exposing a person to what they feel anxious about) with Sally, in the hope that if she
played on the playground again, she’d have fun and be less likely to avoid going there.
To provide some suggestions to Ann for how she could help Sally, I recommended that she also use exposure with Sally,
perhaps by encouraging Sally when she picked her up from school (if convenient for Ann) to play on the playground for ten to
fifteen minutes before going home. At home, Ann and Bill could help Sally by saying what matters to them aloud in front of
Sally, using neutral, everyday examples, such as “Eating healthy is important to me, so I’m going to cook some vegetables
tonight,” then cook vegetables, or “Taking care of my body matters to me, so I’m going to bed early tonight,” then go to bed
early. In this way, Ann and Bill would be modeling to Sally that they were choosing what matters to them, then doing what
matters, which may remind Sally to choose and do what matters to her, instead of avoiding going to the playground.
Session Four: Stay Here and Notice Yourself

It was important to teach Sally to stay here so she would develop greater awareness of when she was caught up in her
thoughts, and not miss out on what was happening around her. To introduce Sally to stay here, I offered her a choice of doing
the exercise Listening to Music While Staying Here (Black, 2016) or Moving Like Seaweed (Saltzman & Goldin, 2008) in our
session (see chapter 5 for further detail about these exercises). Sally selected Listening to Music While Staying Here, and she
enjoyed listening to the music and noticing what she could hear when she concentrated on staying here and listening to the
words and sounds of the instruments.

I asked Sally if she’d like to try to practice staying here in class at school, which she said she would. I suggested that she try
noticing when her attention drifts away and she’s caught up in her thoughts, then bringing her attention back to what she can
hear and what she can see, such as listening to what the teacher is saying and looking at her schoolwork. We discussed how
she might practice staying here in different classes, and Sally was particularly keen to try to practice it in gym and art class.
Then we discussed how Sally might practice staying here at home, and she said she’d like to try to practice this process when
watching television, having a bubble bath, listening to music, and drawing.
Then, to teach Sally about notice yourself, I invited her to participate in the Watching a Movie of Your Life exercise (see
chapter 5 for further detail), which is my favorite notice yourself exercise. I adapted this exercise from Coyne and Murrell’s
(2009) Forgiving a Friend, Forgiving Yourself exercise and Sawyer (personal correspondence, Sawyer, 2012).
Sally was really engaged in this exercise and informed me that prior to doing this exercise, she hadn’t realized how much
she had allowed her thoughts of being worried about having another argument with Kendra to push her around—her thoughts
had stopped her from playing on the playground, getting to know other students, and enjoying herself at school. She added that
it was time to move on from the argument with Kendra and stop believing her mind when it worried about things that might
not even happen. After this exercise, Sally completed the worksheet Watching a Movie of Your Life (see chapter 5 for further
detail; you can download this worksheet in color from http://www.newharbinger.com/49760) in order to have a written reminder
to take home of what she had learned in the session.
At the end of the session, I recommended to Sally that she try noticing herself when her mind comes up with thoughts and
feelings, both at home and at school, and also notice whether she tries to avoid anything or anyone, especially when her mind
comes up with thoughts that worry her. In order to help Sally practice staying here at home, I suggested to Ann that she might
like to teach Sally and all of the family the Eating Dinner While Staying Here exercise. I explained how to do this and pro-
vided Ann with a script (see chapter 5 for the script).
I also mentioned to Ann that she could help Sally practice staying here by watching the sunset with her. Ann could suggest
to Sally that she look at the different shapes of the clouds, colors in the sky, and changing light as the sun sets and encourage
her to stay here and try to notice herself watching the sunset. (This is one of my favorite stay here exercises, which my children
and I regularly enjoy together.)
Session Five: Be Kind and Caring to Yourself

When I first met Sally, she was overwhelmed by her anxious thoughts, leading to immense anxiety about going to school.
Sally wasn’t very resilient when we first met, and had been very dependent on her parents to help her regulate her emotions,
but after just a couple of therapy sessions, she was attending school every day without distress. It was still important to teach
Sally how to be kind and caring to herself so that she could regulate her emotions herself at school or home if she did become
anxious, including in the future.
You can teach children to use kind and caring language to self-soothe when they are distressed, and I find that this often
helps to increase their tolerance for distress, thereby increasing their resilience. To teach Sally how to self-soothe, I invited her
to participate in the Imagine a Kind and Caring Friend exercise (adapted from Bluth’s [2017] and Neff and Germer’s [2018]
Compassionate Friend meditation; see chapter 6 for further detail about both). Sally was very engaged with this exercise: she
concentrated really well and looked very relaxed. Afterward, I asked her several questions about her experience. Sally informed
me that she didn’t have any difficulties imagining what a kind and caring friend would say to her, and she was able to convey
what the friend had said. We then discussed how she could use those kind and caring words to speak to herself in the future,
especially when her mind comes up with worries about school.
After finishing this exercise, I invited Sally to take part in the Write a Kind and Caring Letter to Yourself (Kolts, 2016)
exercise so that she’d have a written reminder to take home of how to speak to herself in a king and caring way. Before she

started the letter, I gave her an example of how she might start it (“Dear Sally, I know that sometimes you get really worried…”),
and she didn’t have any difficulties continuing to write on her own. Then I asked Sally if she’d like to read her letter to me
(assuring her that she didn’t have to), which she wanted to do. Her letter was beautiful and full of kind and caring language.
I suggested to Sally that she might like to ask her parents to make a copy of her letter so she can keep the original at home
and the other in her school backpack. I mentioned that this way she can reread the letter when she’s worried at home or school
or notices that her mind isn’t being kind and caring (the use of the phrase “notice that your mind isn’t being kind and caring”
teaches Sally how to use notice yourself and let it go together with be kind and caring to yourself).
At the end of the session, I recommended to Sally that she try to practice using kind and caring language when she speaks
to herself at home and school, not only when her mind is giving her a hard time, but also when things are going well. For
example, she could say to herself, I did really well at that, I’m proud of myself—great job! or This is really difficult for me, but I’m
trying very hard. I recommended to Ann that she and Bill practice saying kind and caring statements aloud in front of Sally
when they themselves are having difficulties with tasks, and also when they are doing well. This would serve as a model to
remind Sally to be kind and caring to herself.
Session Six: Let It Go and Review

In this session, Sally informed me that she was playing on the school playground each day. She had approached Kendra
and said, “Hello,” and Kendra smiled and said “Hello” back to her. Then, Sally walked away and played with her friends. Sally
reported that occasionally she worried about Kendra, so I revisited the let it go process by inviting Sally to participate in the
Singing Our Thoughts exercise with me, whereby she could sing her thoughts about Kendra, and any other thoughts that
worried her. We both sang our thoughts (I shared the thought that I’m not great at cooking, which was appropriate for disclos-
ing), and we both played musical instruments (see chapter 3 for further detail). Sally participated with much enthusiasm and
had a lot of fun waving a tambourine and shaking sleigh bells while singing her worries about the argument with Kendra.
Afterward, Sally said she didn’t feel as worried about seeing Kendra.
Sally had made terrific progress in our sessions and was doing very well; according to her and her mom, she no longer
reported having stomach pain, was attending school every day without any difficulty, and was informing her parents that she
was enjoying school. Sally also said that she looked forward to playing on the playground at recess and lunch every day and no
longer went to the school nurse’s office, and she even told me she wished she could go to school on weekends! As such, Sally,
Ann, and I agreed that this would be our last session, and that if Sally needed or wanted to see me again in the future, her
parents could contact me to arrange an appointment for her.
I gave Sally lots of positive reinforcement for having been so willing to talk about her thoughts and feelings with me, trying
new techniques for managing her thoughts and feelings, and practicing the strategies in between sessions. Sally reflected on
her progress in therapy, in particular how much she had previously tried to avoid going to school, and how much power her
thoughts had had over her, including having stomachaches when she worried about going to school. Sally informed me that
her life was much better now because she no longer believed everything her mind told her, she felt she could choose what she
wanted to do instead of her mind choosing for her, and she felt that life was more fun now.
I asked Sally what she could recall from previous sessions that she found helpful, and what she had learned that she might
be able to use in the future. Sally told me that each time she had completed a worksheet in our sessions, she put them on the
wall in her bedroom to remind her of what she had learned (see chapters 3 through 6 for worksheets, which can be downloaded
in color from http://www.newharbinger.com/49760). I told her that if she has any difficulties managing her thoughts and feel-
ings in the future, she could look at the worksheets to remind herself what she learned in our sessions, which she thought was
a good idea.

Conclusion
In this extended case protocol, we’ve looked at how I used the ACT Kidflex processes, together with be kind and caring to
yourself, with Sally over six therapy sessions. We also looked at recommendations for home tasks, not only for Sally to practice
what she learned in therapy sessions, but also for her parents, so that they could remind Sally and reinforce the strategies,
making it more likely that Sally would use them herself.
In case you jumped straight to this extended case protocol and didn’t yet read ACT for Treating Children, there you’ll find
more case examples for how to treat children aged five to twelve years for other issues, including depression, obsessive compul-
sive disorder, and separation anxiety disorder. You’ll find many more exercises, detailed transcripts, worksheets, and a case
conceptualization template developed especially for use with children and their parents. (Color versions of the worksheets,
along with the case conceptualization template and some scripts of exercises to give to parents, can be downloaded from http://
www.newharbinger.com/49760.) In the book, I provide recommendations about which exercises are suitable for use with chil-
dren aged five to eight years and for children nine to twelve years. I also show you an extended case protocol along with recom-
mendations for working with parents without treating their child. If you haven’t already, I encourage you to read ACT for
Treating Children to learn how to use the processes of the ACT Kidflex and be kind and caring to yourself with children. Good
luck and enjoy!

ACT for Treating Children Case conceptualization template
Case conceptualization template
ACT Case Conceptualization Template For Children

This is designed to be used as part of taking the child’s history. You can ask the child the questions directly, or ask the child’s
parent(s) or caregivers the questions regarding their child.
1. What is the main problem or difficulty you are having?
(When working with parents: what do you think is the main problem or difficulty your child is having?)
2. When did this start?
3. What do you do when this problem or difficulty shows up or happens?
If the parent is present, you can also ask:

What do you do in response to your child feeling this way?
If the parent isn’t present, you can ask the child:

What does your parent do when you feel like this? Do both your parents respond in the same way?
4. Where does the behavior usually occur, and what happens right before the behavior occurs?

5. What happens right after the behavior occurs?
6. Is this the first time this has been a problem or difficulty for you?
(If the child is unsure or unable to recall, and their parent is present, you can ask the parent this question in relation to the
child.)
If it isn’t, can you remember what you did to try to make things better for yourself previously, or last time?
7. Are you avoiding doing anything, or seeing anyone, or going anywhere because of this problem or difficulty?
If the child answers yes, you can also ask:

Can you think of another time when your mind told you not to do something, because you were (sad/afraid/
worried/etc.), but you did it anyway?
8. Is there anything you are missing out on because of how you try to manage this problem or difficulty?
9. Do you spend a lot of time thinking about this problem or difficulty, and if you do, about how much time per day do you spend
thinking about it, or doing things to avoid it?
10. Do you ever notice yourself thinking about your problem or difficulty, or doing things to avoid it? And do you have any dif-
ficulties concentrating on what’s happening around you, for example, in class, or at home, because you’re thinking about your
problem or difficulty?
12
11. Do you think what you have been doing to manage this problem or difficulty is helping you?
If the child says yes, you can ask:

Does what you are doing create or cause any more problems or difficulties for you?
Or: Is there something you are doing that isn’t helping you?
12. Is what you have been doing working for you?
13. Let’s pretend that I had a magic wand; I wish I did, but I don’t, as magic wands aren’t real, but let’s just pretend that I do. Imagine
it could help you cope with your thoughts and feelings, and you could start doing things that really matter to you, or you could
do these things more often. Perhaps feeling (sad/afraid/worried/etc.) has stopped you from doing this, or stopped you
from doing it often. If you could start doing this thing, or you could do it more often, what would you be doing?
13
ACT for Treating Children Eating While Staying Here
Eating While Staying Here
For this exercise, it’s important to always check with the child’s parent in advance whether they consent to you doing this exercise with
the child during the next session. If the parent consents, I recommend asking the parent to bring something for the child to eat during
the next session, and giving the parents an example of a food that’s suitable for this exercise, such as dried or fresh fruit, vegetable
sticks, or a small candy bar.
Invite the child to take part in this exercise, letting them know that in a moment, you will ask them to pick up the food they have
brought from home, and then you will give them instructions, which you would like them to listen to carefully before eating the food.
The reason I suggest giving these instructions first is that I’ve had the experience where chocolate or candy has been used for this exer-
cise, and the child has eaten it before I’ve finished giving them instructions about what we’re going to do!
The following script was written by Amy Saltzman and Philippe Goldin (Saltzman & Goldin, 2008, p. 147) for eating while staying
here. You can download this script at http://www.newharbinger.com/49760, but remember, you don’t have to use an exact script; you
can make up your own.
Take one bite, paying attention to what is happening in your mouth, noticing the taste. Don’t rush; take one bite at a time,
noting how the taste changes, how your teeth and tongue work… See if you can notice the urge to swallow, and then feel the
swallow as the food moves down your throat… After you have swallowed, when you are ready, take another bite. Take your
time. Be curious about your experience…notice how your body, mind, and heart feel now, in this moment.

ACT for Treating Children Eating Dinner with Your Family
Eating Dinner with Your Family
This is the exercise that I like to recommend to children and parents more often than any other stay here exercise. I find that parents
usually respond quite enthusiastically to this exercise (especially if they are the main cook at home, as doing this exercise might lead to
greater appreciation for their cooking!). In my experience, lots of parents really like the idea of introducing quality, quiet time during
dinner, without the noise of TV, screens, and phones, so engaging in this exercise may help bring this to fruition. I encourage parents to
invite the child to teach it to the whole family once they are seated for dinner, in order to introduce to everyone in the family the skill of
staying here while eating. I suggest to parents that they first give the child a chance to provide the instructions, and then provide help
if needed. (You can download the sample script below from http://www.newharbinger.com/49760 and give the parent a copy to take
home.) The parent might also need to ask other family members to listen while the child is speaking. I introduce this exercise as follows:
Invite everyone in the house to come to the table/counter and eat the meal together. Before starting to eat, tell everyone that
you would like them to try a different way of eating from how everyone usually eats at your home. Ask your family to eat
slowly, in silence, trying to notice the smells of the food, the colors, the textures, and the flavors. You can tell your family that
when their minds drift away, they can try to notice this, and gently bring their attention back to the food. When everyone is
finished eating, each person can have a turn to talk about their experience: What smells, colors, textures, and flavors did they
notice? If the meal was something that they had eaten previously, did it taste the same, or did they notice anything different? If
anyone wants to interrupt while someone else is talking, they can just notice that they wish to speak, and wait their turn. I
recommend changing the order of people speaking each night so that each person gets a turn to speak first.

ACT for Treating Children Under the Sea
Under the Sea
This exercise is adapted from a Baba Ram Dass metaphor. You can introduce it to the child using the following script (available for
downloading at http://www.newharbinger.com/49760), or you can adapt it:
The sea contains different sized waves: sometimes it’s calm and still, at other times it’s stormy. The sea contains waves, sand,
fish, seaweed, and shells, and sometimes other things too, like dolphins and whales. These are all part of the sea, but they are
not the sea. Sometimes it can be really hard to see the sea through all the waves, but the sea is still always there. In the same
way, we have lots of different thoughts and feelings, but we are not our thoughts and feelings. We don’t feel the same way all
the time, and sometimes it’s really hard to notice ourselves having these thoughts and feelings, because of how strong they feel.
For this exercise, you can draw a picture of under the sea, and you might like to include waves that you could write your
thoughts and feelings on. You might also like to draw a treasure chest under the sea that contains all the things that matter to
you, or anything else you’d like to include.
You may have noticed that writing thoughts and feelings on waves is a let it go exercise, and the treasure chest represents the choose
what matters process, which I included in order to teach the child how to combine let it go, choose what matters, and notice yourself.

ACT for Treating Children Worksheet 1: Letting Our Thoughts Be
Worksheet 1:
Letting Our Thoughts Be
What thoughts do you try to tell your mind not to think about?
Is this easy or difficult to do?
What are one or two thoughts you could try to leave alone and just let be, without trying to tell your mind not to think about them?
Now draw a picture of yourself having one of these thoughts and letting it be, without trying to do anything with it:

ACT for Treating Children Worksheet 2: Noticing Our Thoughts Like Cars Driving Past
Worksheet 2: Noticing Our Thoughts

Like Cars Driving Past
Spend a few minutes noticing each thought your mind comes up with, without making any judgments about the thoughts. Now write
some of your thoughts here:
What are two thoughts your mind often has that you could practice just noticing, without judging them?
We can notice our thoughts like cars driving past—just noticing the color, shape, and size of the car without judging the car. Draw some
cars below, then write some of the thoughts your mind often comes up with, writing a different thought above each car:

ACT for Treating Children Worksheet 3: Write a Thank You Card to Yourself
Worksheet 3: Write a Thank

You Card to Yourself
Think about one thing that you do that’s really important to you, for example, taking care of your pet or being kind and
caring to other people. Now write a thank you card to yourself, thanking yourself for doing that one thing. When you’ve
finished, you can decorate the card.

ACT for Treating Children Worksheet 4: The Magic Wand
Worksheet 4: The Magic Wand

Magic wands aren’t real, but let’s pretend that you have a magic wand that could help you cope
with your thoughts and feelings, and that you could start doing things that really matter to
you, or you could do these things more often. Draw a magic wand, and write down some of the
things you could start to do, or do more often.
When you’ve finished, you might like to decorate the magic wand.

ACT for Treating Children Worksheet 5: Staying Here
Worksheet 5: Staying Here

What are some activities you could try to do to practice staying here and really noticing what’s
going on around you, instead of being caught up in your thoughts (for example, listening to music,
drawing, or painting)?
What could you do to help yourself stay here and notice what’s happening around you?
continued on next page

ACT for Treating Children Worksheet 5: Staying Here
Worksheet 5 cont.
Write down the days and times below when you could practice staying here, and include some activities you can do to practice this.
Then, you can draw a picture of each activity.

ACT for Treating Children Worksheet 6: Watching a Movie of Your Life
Worksheet 6: Watching a Movie of Your Life

Imagine that you go to the movie theater and watch a movie of your life. You get to write the title and
watch yourself when you have difficulties coping with your thoughts and feelings (perhaps at home,
school, or other places).
Think about some things you might have noticed the person playing you in the movie doing that aren’t
helpful, or perhaps think about some things the person should try doing differently.
If you could tell the person playing you in the movie something that might help them cope with their thoughts and feelings, what
would you say to them?
Now draw a movie screen below, and on the screen write some things the person playing you could do differently, so they can cope
with their thoughts and feelings better.

ACT for Treating Children Worksheet 7: The Kind and Caring Coach
Worksheet 7: The Kind and Caring Coach

Imagine a very kind and caring coach, who told you that you were trying really hard and doing a
great job. Now draw a coach below, and write down some really kind and caring things this coach
might say to you when it’s hard for you to cope with your thoughts and feelings (for example,
when you feel sad, worried, scared, angry, or something else). Then you can practice saying those
kind and caring things to yourself.


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ACT for Treating Children The ACT Kidf lex

The ACT Kidflex

Let It Be Choose What

(Adapted from Hayes et al., 2006)

Extended Case Protocol: Sally, Eight Years Old

Overview of Sally’s Treatment

OVERVIEW OF SESSIONS WITH SALLY

Session Description Exercises Home Tasks

2 © 2022 Tamar D. Black / New Harbinger Publications.

Session Description Exercises Home Tasks

Six Let It Go Singing Our Thoughts Review worksheets as needed

Session One: Case Conceptualization, History Taking, and Let It Be

3 © 2022 Tamar D. Black / New Harbinger Publications.

Session Two: Let It Be and Let It Go

4 © 2022 Tamar D. Black / New Harbinger Publications.

5 © 2022 Tamar D. Black / New Harbinger Publications.

Session Three: Choose What Matters and Do What Matters

6 © 2022 Tamar D. Black / New Harbinger Publications.

Session Four: Stay Here and Notice Yourself

7 © 2022 Tamar D. Black / New Harbinger Publications.

Session Five: Be Kind and Caring to Yourself

8 © 2022 Tamar D. Black / New Harbinger Publications.

Session Six: Let It Go and Review

9 © 2022 Tamar D. Black / New Harbinger Publications.

10 © 2022 Tamar D. Black / New Harbinger Publications.

Case conceptualization template

ACT Case Conceptualization Template For Children

1. What is the main problem or difficulty you are having?

2. When did this start?

3. What do you do when this problem or difficulty shows up or happens?

If the parent is present, you can also ask:

If the parent isn’t present, you can ask the child:

11 © 2022 Tamar D. Black / New Harbinger Publications.

5. What happens right after the behavior occurs?

If the child answers yes, you can also ask:

If the child says yes, you can ask:

12. Is what you have been doing working for you?

Eating While Staying Here

14 © 2022 Tamar D. Black / New Harbinger Publications.

Eating Dinner with Your Family

15 © 2022 Tamar D. Black / New Harbinger Publications.

Under the Sea

16 © 2022 Tamar D. Black / New Harbinger Publications.

Is this easy or difficult to do?

17 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 2: Noticing Our Thoughts

18 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 3: Write a Thank

19 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 4: The Magic Wand

20 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 5: Staying Here

continued on next page

21 © 2022 Tamar D. Black / New Harbinger Publications.

22 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 6: Watching a Movie of Your Life

23 © 2022 Tamar D. Black / New Harbinger Publications.

Worksheet 7: The Kind and Caring Coach

24 © 2022 Tamar D. Black / New Harbinger Publications.

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ACT for Treating Children The ACT Kidf lex