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Dialectical Behavior Therapy for Children

Dialectical Behavior Therapy for Children

DBT for children (DBT-C) was developed to address treatment needs of pre-adolescent children with severe emotional dysregulation and corresponding behavioral discontrol. These children experience emotions on a different level, and much stronger than their peers. Little things irritate them, and emotions may be so overwhelming that verbal or physical aggression occurs. It may seem at times that these children are manipulative and are trying to push everyone’s buttons. However, the child’s volatile behaviors may indeed be the best way they know how to deal with their intense emotions. Further, these behaviors may continue because they are frequently reinforced (e.g., attention from adults and peers, getting their way when parents finally give in, reduction in the intensity of emotional arousal). The environment may not be ready to effectively manage the challenges such children present, and “good-enough parenting” may not be sufficient to meet these demands. As a child’s needs cannot be adequately met by the environment, the environment frequently invalidates these needs, and destabilizes the child further. A more destabilized child continues to stretch an environment’s ability to respond adequately, which leads to further invalidation, and so forth. This transaction over time may lead to the development of a psychopathology. Indeed, research shows that such children are at an increased risk to develop alcohol and substance use problems, suicidality and non-suicidal self-injury, depression, anxiety, and personality disorders in adolescence and adulthood (Althoff, Verhulst, Retlew, Hudziak, & Van der Ende, 2010; Okado & Bierman, 2014; Pickles et al., 2009). The main goals of DBT-C are to teach these children adaptive coping skills and effective problem-solving and to teach their parents how to create a validating and change-ready environment.

Adaptations to Standard DBT for Pre-adolescent Children

DBT-C retains the theoretical model, principles, and therapeutic strategies of standard DBT and incorporates almost all of the adult DBT skills and didactics into the curriculum. However, the presentation and packaging of the information are considerably different to accommodate for the developmental and cognitive levels of pre-adolescent children. Further, DBT-C adds an extensive parent training component to the model. DBT-C teaches parents everything their child learns (e.g., coping skills, problem-solving, didactics on emotions), plus effective contingency management techniques. DBT-C maintains that parental modeling of adaptive behaviors, reinforcement of a child’s skills use, ignoring of maladaptive responses, validation, and acceptance are key to achieving lasting changes in a child’s emotional and behavioral regulation.

DBT-C aims to stop the harmful transaction between a child and an environment and replace it with an adaptive pattern of responding to ameliorate presenting problems, as well as to reduce the risk of associated psychopathology in the future. In order to incorporate these goals, the hierarchy of treatment targets was greatly extended for DBT-C as compared to DBT for adults and adolescents. While the original DBT hierarchy includes four main categories (life-threatening behaviors, therapy-interfering behaviors, quality-of-life interfering behaviors, and skills training), DBT-C includes three main categories, subdivided into 10 subcategories:

I. Decrease risk of psychopathology in the future

  1. Life-threatening behaviors of a child
  2. Therapy-destroying behaviors of a child
  3. Therapy-interfering behaviors of parents
  4. Parental emotion regulation
  5. Effective parenting techniques

II. Target parent-child relationship

  1. Improve parent-child relationship

III. Target child’s presenting problems

  1. Risky, unsafe, and aggressive behaviors
  2. Quality-of-life-interfering problems
  3. Skills training
  4. Therapy-interfering behaviors of a child

Research Progress for DBT-C

I have recently completed two randomized clinical trials on DBT-C (7-12 years of age) (Perepletchikova et al., manuscript in preparation). The outpatient setting trial targeted children with Disruptive Mood Dysregulation Disorder. Results of this trial indicated that DBT-C was acceptable to children and their parents and was significantly more effective in decreasing DMDD symptoms than Treatment-as-Usual (TAU). DBT-C had a significantly higher rate of attendance, treatment acceptability and satisfaction, and a significantly lower dropout rate as compared to TAU. Further, 90% of children in DBT-C responded to the intervention as compared to 45.5% in TAU, despite three times as many subjects in TAU as in DBT-C receiving additional psychopharmacological treatment. The residential care trial was completed with children (only males) with a range of psychiatric conditions, with ADHD, Disruptive Behavior Disorders and Anxiety Disorders being most prevalent. Significant differences were observed on the main measure of outcome — the Child Behavior Checklist (CBCL), milieu staff report. Children in the DBT-C condition as compared to TAU had significantly greater reduction in scores on both the CBCL Internalizing and Externalizing scales. Results of both trials were maintained at follow-up, and observed changes were clinically significant.

Disruptive Mood Dysregulation Disorder (DMDD) identifies children with severe impairment in self-regulation, who are also highly reactive and sensitive. DMDD is diagnosed if: 1) a child has three or more tempter outbursts per week that are grossly out of proportion to a situation (e.g., punching a sibling for taking his toy, 10 min of screaming “I hate you” when she is told “no”) and are not commensurate with the developmental level of a child (e.g., a 7-year-old has a temper outburst that is more typical of a 3-year-old); 2) child exhibits an angry or irritable mood between outbursts for most of the week (e.g., snappy comments, cursing, mumbling under breath, stomping away, rolling eyes, sighing impatiently); 3) symptoms are present in at least two settings (e.g., at home, school, with peers); 4) symptoms started before 10 years of age, and 5) symptoms have lasted for at least one year.

There is some evidence (please see current research above) that DBT-C may be also helpful to children with other problems, such as depression, anxiety, and disruptive behavior disorders. Further research is needed; however, results obtained so far are encouraging.

Tips for Clinicians Working with Children

  • Don’t be afraid of temper tantrums during a session. They are going to happen anyway, and they can be quite informative and target-relevant. They allow a therapist to: 1) observe parent-child interactions; 2) model to parents how to respond to problematic situations; 3) coach parental responses in the moment; and 4) model effective conflict resolution, problem-solving and skills-use to parents and a child. Ignoring of problem behaviors in session also helps with extinction generalization (e.g., swearing is not attended to at home and in therapy).
  • DBT-C is quite tolerant of a child’s behaviors that may interfere with conducting a session. This stems from its ability to rely almost exclusively on parental learning, when necessary, which significantly relieves the pressure of ensuring the child’s full engagement during a session. In DBT-C problematic behaviors (verbal aggression, threats, cursing, screaming, using threatening body language, devaluing treatment as a waste of time, running around, and other distracting behaviors) are just ignored with a plan to help a child re-regulate and re-focus attention when appropriate. If such behaviors occur consistently, they are targeted by a shaping program.
  • A child’s therapy-interfering behaviors are addressed primarily via 1) developing a strong therapist-child relationship; 2) reinforcing desired behaviors in the moment and shaping adaptive responding over time; 3) ignoring problematic behaviors (except if the behavior is dangerous); 4) relying on natural consequences (e.g., a child does not get a participation reward); 5) conducting a chain and solution analysis of a behavior in subsequent sessions; and 6) if child is not engaging, teaching material to parents with the goal for them to communicate this material to a child at home via modeling, discussions, and prompting, reinforcing and practicing the use of skills.
  • Attempts to correct therapy-interfering behaviors as they are occurring during a session via discussions, behavior analysis, suppression of behaviors via punishment (except if dangerous), etc., can reinforce these behaviors with attention, interfere with addressing higher level targets (e.g., teaching skills to parents), lead to escalation, strain the therapist-child relationship, and decrease a child’s willingness to attend further sessions.
  • During an incident, caregiver’s responses (i.e., remaining calm, validating, using skills, generating effective solutions, ignoring if needed) take precedence over the child’s behavior. If a caregiver is modeling effective behaviors, even if a child has a total meltdown for two hours, the situation has been effectively resolved. In this case, the environment was no longer transacting with a child in a dysfunctional way. If applied consistently, parental adaptive responding over time may result in the creation of a validating environment, and the resulting transaction may help ameliorate the child’s emotional and behavioral dysregulation. Conversely, in a situation when a child responded effectively to a stressor (e.g., used coping skills, walked away to prevent escalation), while parental responses were dysfunctional (e.g., used inappropriate punishment, resorted to screaming or threatening), the incident was not effectively resolved. Without environmental support, the observed child’s adaptive behaviors are likely to remain isolated and sporadic incidents.
  • Skills can be practiced with children in four main ways, such as during: 1) an actual problematic situation; 2) processing of a problematic response after an outburst has occurred and rehearsing alternative solutions; 3) the practice of skills in hypothetical problematic situations via role-plays; and 4) coping ahead of problematic situations that are likely to happen in a near future and deciding on how to respond. Advise parents to practice skills with their children as often as possible. Behavioral rehearsal increases chances of a child using a skill in an actual stressful situation. Further, it increases the frequency of reinforcement for skills use.
  • Motivation is key. Therapists, not only caregivers, need to use tangible rewards. A positive therapist-child relationship is very important and serves as a source of motivation AND tangible rewards can get you further and faster. Use candy, small toys, etc. This will also help with shaping programs.
  • Therapists also can engage in therapy-interfering behaviors. DBT for adults and adolescents highlight a whole range of such behaviors, including a failure to be dialectical (e.g., imbalance of reciprocal versus irreverent communication) and engaging in behaviors that are disrespectful to clients (e.g., coming in late, missing appointments, appearing disheveled). All of these issues apply to DBT-C therapists as well. However, a behavior that may be specifically problematic for a DBT-C therapist is an inability to tolerate intense emotional displays. A therapist’s difficulties with tolerating children’s temper outbursts and other behavioral escalations may lead to attempts to pacify a child in a moment and, thus, a reinforcement of dysfunctional behaviors, as well as modeling of ineffective problem resolution to parents.

Recommended Resources for DBT-C

Currently I have two books in preparation — DBT-C treatment manual and DBT-C treatment handouts and worksheets. The materials are not yet available for distribution to general public. However, Behavioral Tech is starting to conduct DBT-C training workshops. Participants will be provided with treatment handouts and other pertinent materials. There are also several publications on DBT-C that may be of interest:

  • Perepletchikova F, Axelrod SR, Kaufman J, Rounsaville BJ, Douglas-Palumberi H, Miller AL. (2011). Adapting dialectical behavior therapy for children: Towards a new research agenda for paediatric suicidal and non-suicidal self-injurious behaviors. Child and Adolescent Mental Health, 16, 116-121
  • Perepletchikova F, Goodman G (2014). Two approaches to treating pre-adolescent children with severe emotional and behavioral problems: Dialectical behavior therapy adapted for children and mentalization-based child therapy. Journal of Psychotherapy Integration, 24, 298-312.
  • Perepletchikova, F. (in press). Dialectical Behavior Therapy for pre-adolescent children. In, In M.Swales (Ed). Handbook of Dialectical Behaviour Therapy. Oxford: OUP.

Dialectical Behavior Therapy (DBT) is one of relatively few EBPs that has been found to be effective in reducing suicidal ideation and behaviors. For example, among recurrently suicidal individuals with borderline personality disorder, DBT has been found to reduce the rate of suicide attempts by 50% compared to non-behavioral therapy by community experts (Linehan et al., 2006). Within the larger DBT model, there are several important principles that guide treatment for clients at high risk for suicide.

  1. Target suicide directly. In contrast to approaches that attempt to reduce suicide risk indirectly by targeting underlying disorders (e.g., depression), DBT directly targets suicidal thoughts and behaviors as the key problem to be solved. This involves directly assessing the factors that are causing or maintaining specific episodes of suicidal thoughts and behaviors and generating solutions to address these factors.
  2. Thoroughly assess suicide risk. We cannot effectively intervene to reduce suicide risk unless we know that suicide risk is present. Therefore, it is critical that mental health professionals routinely conduct suicide risk assessments, ideally using an evidence-based approach such as the Linehan Risk Assessment and Management Protocol (LRAMP) that is used in DBT. A thorough suicide risk assessment should be conducted at intake with all new clients and when clinically indicated during ongoing treatment (e.g., when a client reports an increase in suicidal ideation). When conducting a suicide risk assessment, it is important to assess direct indicators of suicide risk (e.g., suicidal ideation, plans, and preparation), indirect indicators of suicide risk (e.g., severe hopelessness, access to lethal means), and protective factors (e.g., responsibility to family, belief that suicide is immoral).
  3. Routinely monitor suicidal thoughts and urges. For individuals at high risk for suicide, suicidal thoughts and urges may fluctuate weekly, daily, or even hourly. In addition, high-risk clients may experience weeks or months without any suicidal thoughts only to have those thoughts re-emerge at a later point. It is therefore important that mental health professionals routinely monitor suicidal thoughts and urges, particularly among clients with a history of suicidal behavior. This is done in DBT by having clients complete a diary card that includes daily ratings of urges to kill oneself. In addition, DBT therapists ask clients to provide a rating of current urges to kill themselves at the beginning of each therapy session. This kind of routine monitoring is critical to enable therapists to intervene when suicide urges are high, as well as to assess the factors that lead to increases and decreases in suicidal urges over time.
  4. Reduce the use of psychiatric hospitalization. DBT aims to provide treatment to high-risk clients in the least restrictive setting possible. This means that DBT therapists do not typically recommend or rely on psychiatric hospitalization when suicide risk is high. This approach is based on the lack of empirical evidence that psychiatric hospitalization reduces suicide risk, and concern that it may increase long-term risk. In addition, the DBT model assumes that people cannot have a reasonable quality of life if they are constantly going in and out of psychiatric hospitals, and that clients must learn how to reduce suicide risk while remaining in their natural living environments. Accordingly, many studies have shown that DBT greatly reduces the use of costly crisis services, such as psychiatric hospitalizations and emergency room visits, while simultaneously reducing suicidal behaviors.
  5. Provide skills-based solutions to reduce acute suicide risk. In DBT, suicide is viewed as the client’s effort to solve a problem, typically intense emotional pain that the client feels unable to change or tolerate. To reduce immediate suicide risk, the therapist must help the client to identify and implement alternative solutions to the problem. DBT teaches clients four sets of behavioral skills to increase their ability to regulate emotions, tolerate distress, improve relationships, and live mindfully. The goal is for clients to use these skills to prevent suicide urges from increasing and to not act on suicide urges when they are present. Research has shown that use of DBT skills leads to reductions in suicidal and self-injurious behaviors (e.g., Neacsiu, Rizvi, & Linehan, 2010), indicating that learning and using skillful coping strategies is critical to reducing suicide risk.
  6. Identify and work towards long-term solutions to suicide. Although solutions to address acute risk are critical, it is equally important for therapists to help clients identify solutions that will reduce suicide risk in the long term. In DBT, the ultimate goal of treatment is to help clients build a life worth living. Simply put, we must help clients develop a life in which suicide is no longer viewed as a viable or necessary option. To do this, therapists must understand what exactly would need to be different for the person to want to be alive, and then tenaciously work with clients to achieve those life changes. Often this involves working on value-driven goals that may be slower to change, such as developing positive and lasting relationships, finding ways to make meaningful contributions to others, and achieving financial stability. Success stories of DBT clients provide hope that it is indeed possible for highly suicidal people to build lives worth living.
  7. Therapists must be available to clients between sessions. Individuals at high risk for suicide often require in-the-moment coaching to navigate difficult situations without resorting to suicide. In DBT, this is done by making therapists available to clients for phone coaching between sessions. Coaching calls are typically brief and focused on helping clients identify skills to effectively manage current and ongoing difficult situations. Importantly, DBT includes several strategies to reduce the likelihood that these between-session contacts may inadvertently reinforce suicidal behavior. For example, DBT uses the “24-hour rule” that makes therapists unavailable for between-session contact for 24 hours after any suicide attempt or non-suicidal self-injurious behavior. This rule is designed to make sure that these behaviors are not inadvertently reinforced by contact with a caring therapist immediately afterwards.
  8. Therapists require support and consultation. Mental health professionals working with high-risk clients need support. It can be scary and exhausting to live with the constant worry that one’s clients may die by suicide. In addition, being available to high-risk clients between sessions means that therapists must be prepared to intervene in a suicidal crisis at any moment. When working with high-risk clients, it is also recommended that therapists seek consultation to determine the most effective way to intervene. To address this, DBT requires therapists to participate in a therapist consultation team consisting of a team of providers working together to deliver DBT to a community of clients. The primary functions of the therapist consultation team are to provide therapists with support, increase therapist motivation and reduce burnout, and increase therapist competence. Ideally, the therapist consultation team helps therapists feel ready and able to stay engaged in this challenging yet highly rewarding work.

Francheska Perepletchikova, Ph.D. is a DBT-Linehan Board of Certification Board Certified Clinician and is an Assistant Professor of Psychology at the Department of Psychiatry at Weill Cornell Medical College. Dr. Perepletchikova received her B.A. degree at St. John’s University and graduated with a gold medal for the highest academic average. Dr. Perepletchikova received graduate training in two disciplines — developmental and clinical psychology. She obtained an M.A. in Developmental Psychology from Teachers College, Columbia University in 1996 and received Ph.D. in Clinical Psychology from Yale University Department of Psychology in 2007 (with the James B. Grossman Best Dissertation Prize). As a clinician, Dr. Perepletchikova maintains her practice at Weil Cornell Medical College, where she is a Founding Director of Youth-Dialectical Behavioral Therapy Program and a Director of Outpatient Adolescent DBT Program. Read more about Francheska Perepletchikova here.