Understanding Dialectical Behavior Therapy for Children (Part 1)

July 21, 2020

This feature by Francheska Perepletchikova, PhD is Part 1 of 3 in a series about understanding DBT-C, presented in a question and answer format. In this first part, we define DBT-C, address the target population and the most frequent diagnosis, and examine how symptoms may differ from other disorders.

Question: What is Dialectical Behavior Therapy for pre-adolescent children?

Francheska: Dialectical Behavior Therapy for pre-adolescent children (DBT-C) is an intervention developed to treat children with severe emotional and behavioral dysregulation. It has been adapted from standard model DBT for adults. 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 and validation techniques.

Question: What is the target population of DBT-C?

Francheska: Some children are born emotionally sensitive. Like everything else, emotional sensitivity has two sides. On the one hand, emotionally sensitive children are likely to experience positive emotions on a high level, can read other people’s emotions, can be very caring, understanding and empathetic to others, and usually are quite creative. On the other hand, emotional sensitivity presents with challenges, such as these children’s emotional reactions have a lower threshold for occurrence, are more intense, happen faster and take a longer time to subside, than those in a regular population. In DBT-C, we call these children supersensers, analogous to supertasters and supersmellers, and their emotional sensitivity as a superability, as it gives them benefits described above. Using the term supersenser avoids pathologyzing and helps children feel understood, validated and not judged, which decreases their self-critical thinking and increases their willingness and interest to learn what we term ”super-skills” to help achieve control over their “super-abilities.”

Many supersensers are well adjusted and enjoy the benefits of their emotional sensitivity, and can deal effectively with the challenges it presents. DBT-C is used to treat children who develop emotional dysregulation and corresponding behavioral dyscontrol. They exhibit angry/irritable mood, have temper tantrums, frequently are destructive, verbally and physically aggressive, and may have suicidal ideation and engage in non-suicidal self-injury (NSSI). They tend to have severe interpersonal difficulties with family members and peers, extreme thinking style, low tolerance for delayed gratification, low tolerance for change and transitions, difficulty with concentration and rapidly shifting attention, difficulty with tolerating boredom, hyperactivity, impulsivity, and may have sensory processing problems. Without treatment, these children may fail to learn self-regulation and may have persistent difficulties in multiple settings. The negative feedback may lead to the development of negative self-concept, and impede their emotional, social and cognitive development.

Question: What is the most frequent diagnosis given to such children?

Francheska: The most frequent diagnosis given to children with severe emotional and behavioral dyscontrol is Disruptive Mood Dysregulation Disorder (DMDD). 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 a toy; 30 min of screaming “I hate you” when told “no” to having ice cream before dinner) 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) the 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.

Question: Behavioral problems that you are describing for DMDD are similar to symptoms observed in children with Oppositional Disruptive Disorder and Conduct Disorder. So what’s the difference?

Francheska: Let’s take a continuum with two poles: emotional sensitivity and callous unemotional. Children with DMDD are closer to the emotional sensitivity side, while children with Conduct Disorder are closer to callous unemotional side. Behavioral symptoms specified in Oppositional Defiant Disorder can be readily observed on both sides. So what is the difference? Emotionally sensitive children have reactive aggression, while callous unemotional children tend to have proactive aggression. Reactive means that it occurs in response to a stressor that triggers an intense emotional reaction and its main function is to decrease emotional arousal. Proactive means that it occurs without an immediate stressor, is not triggered by an emotional arousal and its main function is instrumental (to obtain something from another person). Of course reactive and proactive aggression can happen on both sides of the spectrum. Here we are talking about prevalence.

Read here for Part 2 of this blog post, in which Francheska discusses how emotional dysregulation develops, what kind of parenting is needed, and the main goals and primary treatment targets of DBT-C.

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 is a Founding Director of Youth-Dialectical Behavioral Therapy Program, that provides services to children, adolescents and young adults with a range of psychiatric conditions. Dr. Perepletchikova maintains her clinical practice at White Plains, NY. Read her full biography on the Behavioral Tech Institute website here.


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