Childhood depression: the CBPT assessment & treatment approach
A practitioner’s guide to recognising depression in children — where it often looks like irritability and withdrawal — and treating it with Cognitive Behavioral Play Therapy, under the scientific direction of Maria A. Geraci and Susan M. Knell.
Train in the CBPT protocol for childhood depressionScientific direction: Maria A. Geraci and Susan M. Knell
Five-phase clinical pathway
For child psychotherapists
A depressed child rarely says ‘I am sad’. They show it — in play, in withdrawal, in irritability. Our task is to read it and answer.
— CBPT Research Center
When the colour drains out of childhood
Childhood depression is easy to miss because it seldom looks like adult sadness.
It can present as irritability, boredom, somatic complaints, falling grades, loss of interest in play and friends, and a flatness that adults may read as laziness or defiance. The child withdraws from the very things that used to bring relief. For the clinician, the presenting picture is a child who has quietly stopped engaging with the world around them.
“Nothing is fun anymore — and I don’t even know why.”
Understanding depression in children
A clinical overview: what childhood depression is, how its symptoms present, how it differs from ordinary sadness, and the factors that cause and maintain it.
Depressive disorder (DSM-5-TR) — includes major depressive disorder and persistent depressive disorder
Depressed or irritable mood, or loss of interest/pleasure, causing significant distress or impairment
Can occur at any developmental stage; irritability often replaces sadness as the primary mood presentation in children
May persist or recur; impairs school, social and family functioning and increases long-term risk
Assessment must include evaluation of suicidal ideation and safety as part of competent clinical care
Behavioural activation, adaptive cognitive work and family involvement delivered through developmentally appropriate play
What is childhood depression? (DSM-5-TR)
Major depressive disorder requires five or more symptoms over at least two weeks, representing a change from previous functioning — with depressed or, in children, irritable mood as a possible anchor symptom.
Depressive disorders in children are characterised by low or irritable mood and a range of associated emotional, cognitive, somatic and behavioural symptoms that represent a change from the child’s typical functioning. Major depressive disorder (MDD) requires the presence of five or more of the following symptoms during the same two-week period, with at least one being either depressed mood (or irritable mood in children) or loss of interest/pleasure: depressed or irritable mood; markedly diminished interest or pleasure in activities; appetite or weight change (or, in children, failure to make expected weight gains); sleep disturbance; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive guilt; difficulty concentrating; and recurrent thoughts of death or suicidal ideation (APA, 2022). Persistent depressive disorder (dysthymia) in children requires depressed or irritable mood present most days for at least one year, with two or more associated symptoms. In both presentations, symptoms must cause clinically significant distress or impairment in social, academic or other areas of functioning, and must not be attributable to a substance or another medical condition.
Symptoms & presentation in children
Childhood depression often presents through irritability, somatic complaints and disengagement from play rather than the verbal sadness more typical of adult presentations.
Clinicians should be alert to the full range of depressive signs, which in children frequently include:
- Irritability, frustration or low frustration tolerance rather than overt sadness
- Loss of interest or pleasure in play, hobbies and activities previously enjoyed
- Social withdrawal and reduced interaction with peers and family
- Somatic complaints: headaches, stomach aches and fatigue without clear medical cause
- Academic decline and difficulty concentrating
- Sleep and appetite changes (or, in younger children, failure to make expected weight gains)
- Low self-worth, excessive guilt and negative self-appraisal
Because children often lack the vocabulary to label internal states, and because depression in this age group can be masked by externalising or somatic presentations, a multi-informant approach — drawing on parent reports, teacher observations and direct child assessment through play — is essential for accurate clinical formulation.
Depression vs ordinary sadness
Clinically significant childhood depression is distinguished from the transient sadness that is a normal part of development.
Sadness, grief following loss, and low mood in response to stressful events are normal experiences in childhood. They are typically reactive, time-limited and do not impair functioning across multiple domains. Childhood depression, by contrast, is pervasive and persistent — lasting at least two weeks for MDD or at least one year for persistent depressive disorder — and causes meaningful impairment in school performance, social relationships and family life. The mood is not simply a response to an identifiable stressor; it is present most of the day, on most days, and does not lift with positive events or pleasurable activities. The distinction is clinically critical because it determines whether watchful waiting, consultation or structured clinical intervention is appropriate.
Differential diagnosis
Childhood depression must be distinguished from other conditions that share overlapping features.
- Adjustment disorder: low mood is a direct, time-limited response to an identifiable stressor and resolves once the stressor or its consequences have passed; MDD is not fully explained by a stressor and persists beyond an adjustment period.
- Anxiety disorders: significant symptom overlap exists; anxiety and depression co-occur frequently and must each be formulated in the treatment plan.
- ADHD: inattention, poor concentration and dysregulation can mimic depressive symptoms; careful history distinguishes a change from baseline (depression) from a longstanding pattern (ADHD), though both may co-occur.
- Disruptive mood dysregulation disorder (DMDD): characterised by persistent irritability and severe, recurrent temper outbursts disproportionate to the situation; differs from MDD in its chronicity and the predominance of outbursts rather than episodic mood change.
- Bipolar disorder: when assessing depressive episodes in children, clinicians should evaluate for a history or risk of hypomanic or manic episodes, as treatment implications differ substantially.
- Medical causes: thyroid dysfunction and other medical conditions can produce depressive symptoms and should be ruled out as part of a thorough assessment.
Common comorbidities
Childhood depression frequently co-occurs with anxiety disorders, ADHD and disruptive behaviour disorders. These comorbidities shape both the clinical presentation and the treatment approach; a thorough assessment screens for each so that the formulation and intervention plan can address the full clinical picture.
Safety assessment
Assessment of suicidal ideation and safety is an integral part of competent clinical care for childhood depression.
Depressive disorders in children can be associated with passive thoughts of death, active suicidal ideation and, in some cases, suicidal behaviour. Competent clinical assessment includes systematic evaluation of suicidal ideation, intent, plan and access to means, as well as protective factors. Where indicated, risk-appropriate referral, coordination with other professionals and safety planning are part of the clinical framework within which CBPT is delivered. Clinicians working with depressed children are expected to maintain familiarity with current risk-assessment and referral pathways in their clinical context.
Onset, course & epidemiology
Depressive disorders can emerge at any developmental stage, including early childhood, and frequently recur without adequate intervention.
Depressive episodes can occur across the lifespan, including in preschool and school-age children, though prevalence increases markedly in adolescence. The course is variable: some children experience a single episode with full remission, while others show a recurrent or chronic course. Risk of recurrence is substantial, particularly when earlier episodes are not fully treated. Early identification and structured intervention are therefore clinically important not only for immediate relief but also for long-term developmental trajectory. The impact on academic achievement, social development and family relationships can be significant and cumulative.
Causes & maintaining factors (CBPT conceptualization)
Childhood depression arises from the interaction of temperament, negative cognitive style, reduced positive reinforcement and interpersonal context — all addressed within the CBPT framework.
Several groups of factors contribute to the onset and maintenance of childhood depression. Temperamental factors: negative emotionality, behavioural inhibition and a tendency toward negative self-appraisal are associated with increased vulnerability. Environmental and interpersonal factors: adverse life events, loss, family conflict and reduced access to positive social reinforcement can trigger and maintain low mood; interpersonal relationships — particularly with caregivers — are both a context for and a resource in intervention. Cognitive maintaining factors: a negative cognitive style (negative views of the self, the world and the future) interacts with behavioural withdrawal to reduce contact with positive experiences, perpetuating low mood in a self-reinforcing cycle.
In the CBPT conceptualisation, the core maintaining mechanism is the interaction of low mood, behavioural withdrawal and the resulting loss of positive reinforcement: the child withdraws from activities and relationships that could provide mastery and pleasure, which deepens the depression and further reduces motivation to engage. CBPT — a structured, brief, goal-oriented therapy — addresses this cycle directly: behavioural activation through play re-engages the child with pleasurable and mastery experiences; cognitive work adapted developmentally through play targets negative self-talk and appraisals; and the family is actively involved to support activation, model adaptive coping and help rebuild positive daily routines.
The CBPT treatment protocol
A structured, brief and goal-oriented pathway for delivering cognitive behavioral therapy for childhood depression through play: from shared therapeutic goals, through the child’s five-phase work with behavioural activation and adaptive thinking, to the parallel parent-training track and the change clinicians can expect to see.
Therapeutic goals
CBPT is well suited to childhood depression because it rebuilds engagement, positive experience and adaptive thinking through developmentally appropriate play.
In CBPT, goal-setting is shared with the child and family. The aim is to teach skills that help the child understand, think about, interpret and respond effectively to events — interrupting the withdrawal-and-low-mood cycle that maintains depression. In the context of childhood depression, the protocol generally pursues:
- developing emotion-regulation capacities;
- direct teaching of anxiety-management and self-regulation techniques;
- developing problem-solving skills;
- psychoeducation for both parents and child.
Crucially, both parents and child should start from the awareness that the child is not responsible for the disorder, that symptoms are separate from who the child is, and that all stakeholders — parents, teachers and therapists — share responsibility for addressing the current struggles.
Working with the child — phase by phase
The intervention is organised into five sequential phases, from orientation to follow-up.
Orientation Phase
The initial phase of CBPT places significant emphasis on preparing both the child and the parents. An initial meeting between therapist and parents — without the child — reviews the child’s history and background in detail and lets parents share their perception of the problem. In depression, this phase also focuses on building a warm, hopeful therapeutic alliance and reintroducing pleasurable play as an early, low-demand intervention that signals that things can be different. The therapist helps parents prepare the child for the first session and explains the ongoing role of parents and other significant adults across assessment and treatment.
Assessment Phase
This phase collects the information needed to establish shared, goal-oriented therapy targets. Beyond interviews with parents, structured observation of the child’s play is a key element. The assessment gauges mood, interest, somatic and school signs, and evaluates safety; a baseline of activity level, withdrawal patterns and negative self-statements is established so change can be measured objectively over treatment. Tools include questionnaires administered to parents, assessment of the child’s play, a puppet sentence-completion task, and other measures personalised by the therapist.
Case Conceptualization Phase
CBPT analyses the data gathered during assessment to plan effective treatment and provide a logical structure for developing and achieving goals. For the depressed child, this means mapping the specific low-mood → withdrawal → fewer positive experiences → lower mood cycle for this particular child, alongside the temperamental, cognitive and interpersonal factors that sustain it. The conceptualisation informs the sequencing of behavioural and cognitive targets in the intervention phase.
Intervention Phase
This phase uses CBT techniques adapted through play to help the child develop more adaptive responses to problems, situations and stressors, emphasising adaptive thoughts and behaviours. For depression, the core mechanisms are behavioural activation — re-engaging the child with pleasurable and mastery activities through structured play — and developmentally appropriate cognitive work addressing negative self-talk, hopeless thinking and low self-worth. Methods include modeling, role-playing, bibliotherapy, generalization and relapse prevention; traditional cognitive techniques are adapted through drawing, expressive arts, therapeutic storytelling and puppets, with explicit work on generalising learned behaviours. Regular parent meetings continue to monitor progress and support family-level activation.
Conclusion Phase
Both child and family are actively involved in the final phase. The child addresses feelings related to ending therapy while the therapist highlights the changes achieved and consolidates gains, relapse-prevention strategies and ongoing monitoring plans as needed. Final sessions may be spaced from weekly to biweekly or monthly, helping the child perceive their ability to manage life without the therapist. Positive reinforcement is provided for progress between sessions and the separation is normalised. Follow-ups are scheduled at 3, 6, 12 and 24 months to verify the effectiveness of the intervention and coordinate ongoing support where indicated.
Learn to deliver every phase in session
Master the five-phase clinical sequence with the child — the play-adapted CBT techniques, behavioural activation, cognitive work through play, the in-session sequencing and the assessment battery — under the scientific direction of Maria A. Geraci and Susan M. Knell.
Get the complete in-session protocolThe structured 16-week treatment protocol
For childhood depression, the protocol is typically organised across roughly 16 weeks, individualised to the child’s profile.
Each session follows a consistent structure: review of the previous week, reaffirmation of goals, presentation of new information or skill, targeted behavioural or cognitive work, practice of relapse prevention, and assignment of homework for the following week. A common arrangement progresses from psychoeducation and alliance-building through the systematic introduction of behavioural activation targets, mastery and pleasure activities, and cognitive work on negative self-appraisal, to consolidation and relapse prevention in the final weeks.
- Early weeks — psychoeducation, alliance-building, activity scheduling and identification of pleasurable play targets;
- Middle weeks — graded behavioural activation, mastery and pleasure activities, cognitive work on negative self-talk adapted through play;
- Parent sessions — integrated throughout to support activation at home and coordinate monitoring;
- Final weeks — consolidation of gains, relapse prevention planning and preparation for termination;
- Follow-up — coordinated monitoring and booster sessions as clinically indicated.
The intervention is reinforced by a Playbook: a family resource of weekly play-based activities, a copy of the treatment plan and the therapeutic agenda, plus worksheets to monitor mood, activity levels and negative self-statements and to track the impact of behavioural activation. The Playbook becomes the family’s transitional object, carrying therapy skills into the child’s everyday world.
Working with the family — parent training
While the child follows the five-phase CBPT protocol, parents follow a parallel five-phase training programme.
A competence-based pathway brings parents into the playroom to shape adaptive behaviours.
Parent Training is a competence-based intervention model that assumes families are capable of managing the problem, that every family has strengths, and that parents can learn new skills. Integrated into CBPT, it brings parents into the playroom to observe and progressively implement interventions that shape adaptive behaviours in the presence of the therapist, aiming to modify relational styles and attitudes that negatively affect children’s behaviour.
Parents are taught to understand the factors contributing to the child’s symptoms, the cues and events that trigger mood changes, and behaviour-management strategies that enhance self-esteem rather than shame the child — alongside the principles of a collaborative problem-solving approach (Greene) that respects both the parent’s and the child’s point of view.
Through this approach, parents have the opportunity to:
- Learn new skills.
- Acquire and practise specific techniques.
- Receive individualised, ongoing feedback from the therapist to increase their awareness.
- Interpret more accurately their children’s emotions, concerns and communication expressed through play.
This program, called PARENT TRAINING CBPT, follows an integrated and innovative approach. Although the primary work is with the child, periodic meetings with parents are essential during both assessment and treatment: this pathway runs parallel to the child’s therapy, emphasising the role parents play in influencing maladaptive behaviours. Parents are encouraged to reinforce adaptive child behaviours so treatment continues outside the therapy setting (using appropriate reinforcement for adaptive behaviours and extinction for maladaptive ones).
The parent-training pathway — five phases
Assessment
The problem is analysed, parenting style is adapted and therapeutic goals are defined. Parents receive information about the causes and consequences of their child’s depressive presentation and learn to establish clear, consistent patterns of positive reinforcement that support behavioural activation at home.
Learning
This phase teaches the new skills needed to support change. Parents learn and practise specific techniques through role-play sessions in which the therapist acts as the child. Key targets include:
- mastery of prerequisites;
- modeling of skills;
- role-playing;
- errorless learning;
- successive approximations (shaping);
- feedback (verbal and social reinforcers, token economy);
- repeated practice.
Practice
Parents carry out play sessions with their own children to apply the skills learned, recognising and preventing situations that trigger withdrawal and low mood, and using consistent problem-solving strategies across contexts. After initial practice with the therapist, parents begin to run individual play sessions under supervision.
Review
Parents discuss at length with the therapist the home play sessions to learn how to generalise what they have learned. Strengths and any problems are reviewed; the therapist helps generalise the interventions and parenting skills acquired. Each week, time is dedicated to applying techniques in everyday life and homework is assigned to practise the strategies.
Conclusion
Reached when therapeutic goals have been met and parents have achieved a satisfactory level of competence in play activities and parenting skills. Therapy is tapered gradually, reducing session frequency to every other week, then monthly, and so on.
Objectives of parent training — specific goals
This program helps parents interact effectively with their child by developing functional behavioural and communicative habits and techniques, removing the conditions that give rise to problem behaviours and replacing them with adaptive, socially desirable conduct.
Understanding behaviour
Increase understanding of the child’s problematic behaviour.
Realistic expectations
Set more realistic expectations.
Warmth & acceptance
Increase warmth, trust and acceptance toward the child.
The value of play
Recognise the importance of interaction through play.
Effective communication
Communicate more effectively with their children.
Parental confidence
Develop greater confidence and reduce frustrations experienced with their children.
Patience
Cultivate greater patience to create more realistic expectations.
Self-understanding
Discuss personal reactions with the therapist to understand their own feelings and behaviours.
Problem solving
Become effective problem solvers of family conflicts and develop stronger motivation for change.
The course includes the full parent-training pathway
Deliver the integrated parent-training track alongside the child’s protocol — the five parent-track phases, the competence-based model and the Playbook structure that carries change beyond the playroom.
Train in CBPT Clinical Applications — full programWhat change looks like
As the child re-engages with pleasurable activities and builds adaptive ways of thinking about themselves and their world, mood lifts and withdrawal recedes.
Through behavioural activation delivered in play, the child gradually re-engages with activities that bring mastery and pleasure, breaking the withdrawal cycle. As adaptive thinking skills grow and negative self-appraisal loosens its hold — and with parents supported to reinforce positive engagement at home — progress reaches beyond the therapy room into school and everyday life, with follow-ups confirming that the gains hold.
Train in the full assessment-and-treatment protocol for childhood depression.
Train in the CBPT protocol — Clinical Applications programChildhood depression & CBPT: clinical FAQ
Why does childhood depression present as irritability?
The DSM-5-TR explicitly allows irritable mood in place of depressed mood as an anchor criterion for depressive disorders in children and adolescents. In developmental terms, children who lack the verbal and emotional vocabulary to articulate internal sadness often express low mood behaviourally — through frustration, reactivity, irritability or somatic complaints. Recognising irritability as a depressive equivalent rather than a conduct or behaviour problem is clinically critical for accurate formulation and appropriate intervention.
How does play-based work treat low mood?
CBPT addresses childhood depression through two primary mechanisms adapted into play: behavioural activation, which systematically re-engages the child with pleasurable and mastery activities that break the withdrawal–low-mood cycle, and developmentally appropriate cognitive work addressing negative self-talk and appraisals through drawing, storytelling and puppet play. The play medium is not incidental — it is the developmentally calibrated language through which the child can engage with and process material that would be inaccessible in a verbal-only format.
How is safety handled?
Risk assessment and appropriate referral and coordination are integral to competent clinical care for childhood depression. Assessment of suicidal ideation, intent, plan and access to means, alongside protective factors, is part of the clinical framework. CBPT is delivered within a responsible, ethically grounded clinical context; where risk is identified, safety planning and coordination with other professionals are part of the clinical response. Clinicians are expected to maintain current knowledge of risk-assessment and referral pathways in their specific setting.
What is the family’s role?
Family involvement is central to the CBPT model for childhood depression. Parents follow a parallel five-phase parent-training pathway that equips them to support behavioural activation at home, model adaptive coping, help rebuild positive daily routines, and reinforce adaptive behaviours rather than inadvertently accommodating withdrawal. Periodic parent meetings run throughout assessment and treatment, and the Playbook structure ensures that the skills and activities developed in session are transferred into everyday family life.
How long is treatment?
The CBPT protocol for childhood depression is typically organised across roughly 16 weeks, though duration is individualised to the child’s profile, severity, comorbidity and response. Sessions follow a consistent structure — review, goal reaffirmation, skill introduction, targeted work and homework assignment — with parent sessions integrated throughout and follow-up monitoring scheduled at 3, 6, 12 and 24 months to confirm that gains are maintained and to coordinate any ongoing support indicated by the clinical picture.
Train in the full protocol
Master the complete CBPT assessment-and-treatment protocol for childhood depression — five clinical phases, behavioural activation and cognitive work through play, and the parent-training pathway.
Enrol in the CBPT Clinical Applications programBibliography
The clinical framework, assessment battery and phase-by-phase protocol described above are grounded in the CBPT literature and in DSM-5 / DSM-5-TR, under the scientific direction of Maria A. Geraci and Susan M. Knell.
- American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
- Geraci M. A. (2022). La play therapy cognitivo-comportamentale. Armando Editore. Roma
- Geraci M. A. (2023). Comprendere il mondo dei bambini giocando. Armando Editore. Roma
- Geraci M. A. (2024). Il mondo della dottoressa Lulù. Collana Amazon - CBPT Books.
- Greene, R. W. (2014). The Explosive Child (collaborative problem-solving approach).
- Knell S. M. (1993). Cognitive Behavioral Play Therapy. J. Aronson.
CBPT Research Center — Training Programme
Professional Training in CBPT for Childhood Depression
The CBPT Research Center develops and delivers evidence-based postgraduate training for psychologists, psychotherapists and clinical specialists. Our certified curriculum includes a dedicated module on the CBPT approach to Childhood Depression, grounded in peer-reviewed research and clinical practice.
View the training curriculumThe in-session protocol
Skills you can apply in session — under the scientific direction of Susan M. Knell, originator of CBPT.