Dialectical Behavior Therapy for Pre-adolescent Children

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Abstract and Keywords

Dialectical Behavior Therapy for pre-adolescent children (DBT-C) targets severe

emotional and behavioural dysregulation in the paediatric population by teaching

adaptive coping skills and helping parents create a validating and a change-ready

environment. It 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. Additionally, the treatment target hierarchy has been greatly expanded to

incorporate emphasis on the parental role in attaining child’s treatment goals. This

chapter discusses the theoretical model, presents the treatment target hierarchy,

provides an overview of the adaptations made to skills training and individual therapy,

discusses the addition of the parent training component, and finally, briefly presents an

empirical evidence for the model.

Keywords: Dialectical Behavior Therapy, DBT, pre-adolescent children, emotion regulation, psychotherapy

Dialectical Behavior Therapy for Pre-adolescent

Children

Francheska Perepletchikova

The Oxford Handbook of Dialectical Behaviour Therapy

Edited by Michaela Swales

Subject: Psychology, Clinical Psychology Online Publication Date: Aug 2017

DOI: 10.1093/oxfordhb/9780198758723.013.25



Oxford Handbooks Online

Dialectical Behavior Therapy for Pre-adolescent Children

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Box 1: Key Messages for Practitioners

• DBT-C retains the theoretical model, principles, and therapeutic strategies of

standard DBT.

• DBT-C incorporates almost all of the adult DBT skills and didactics into the

curriculum, but modified to the developmental and cognitive level of pre-adolescent

children.

• DBT-C includes a parent-training component.

• A major departure from standard DBT is the treatment target hierarchy, which

emphasizes increasing adaptive patterns of parental responding as central to

improving the child’s emotional and behavioral regulation.

Theoretical Model

Biosocial Theory

Biosocial Theory (Linehan, 1993) suggests that individuals with emotional dysregulation

are usually born sensitive or vulnerable to their emotions, and are unable to effectively

modulate their emotional experiences. They display high emotional arousal, high

reactivity, and a slow return to baseline. Parents often describe these children as “going

from a 0 to a 100 in a split second.” Additionally, events that trigger these extreme

emotional reactions are not always due to the external environment, and instead may

involve just a thought, memory, or stressor so minute it is indiscernible to observers.

Children with emotional dysregulation problems often describe their emotional

experiences as “tsunamis” that are quite overwhelming, painful, and almost impossible to

control.

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 children’s

needs. Winnicott’s (1973) concept of “good enough parenting” focused on the parental

ability to survive a child’s anger at the world and their shock of the loss of the

omnipotence, as well as to help the child accept reality and relate to it in more realistic

terms (Bingham & Sidorkin, 2004; Phillips & Taylor, 2009). With emotionally dysregulated

children, surviving the child’s frustration with reality frequently becomes an almost

insurmountable challenge for both child and parent. This inborn sensitivity significantly

exacerbates the child’s frustration, as well as feelings of parental hopelessness and

defeat because they do not understand the reasons for, nor have methods to deal with,

their child’s reactivity.

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This poor fit between a child’s needs and the parental ability to satisfy them may create

an invalidating environment over time. It is reasonable to expect that “good enough

parenting” will include some level of direct criticism, punishment, and dismissal of a

child’s feelings, thoughts, and behaviours as invalid. What makes an environment

invalidating is the pervasive nature of such events. The invalidating environment

indiscriminately rejects private experiences and behaviours as invalid (e.g., “Why are you

angry? There is nothing to be angry about!”), oversimplifies the ease of solutions (e.g.,

“Just snap out of it,” “Why can’t you be like your brother?”), and intermittently reinforces

escalated emotional displays (e.g., child learns that s/he can receive the coveted care and

support primarily when she threatens suicide to communicate suffering, while lower

levels of such expression are invalidated).

An invalidating environment fails to teach a child how to 1) label private experiences; 2)

trust experiences as valid responses to events; 3) accurately express emotions; 4)

communicate pain effectively; 5) use self-management to solve problems; and 6)

effectively regulate emotions. Instead, an invalidating environment teaches a child how to

1) respond with high negative arousal to failure; 2) form unrealistic goals and

expectations; 3) rely on the external environment for cues on how to respond; 4) actively

self-invalidate; and 5) oscillate between emotional inhibition and extreme responses.

Transactional Model

Thomas and Chess (1985) have extensively discussed the notion of the “poorness of fit”

between an environment and a child as a critical factor in the etiology of

psychopathology. They have also highlighted the pattern of reciprocal influence in the

child-environment system. Indeed, the characteristics of a child and an environment are

not static, but rather change through reciprocal interaction or transaction where

components continuously adapt to each other. Such mutual influence may lead to an

exacerbation of a child’s emotional dysregulation, as well as the development of an

invalidating environment. When a child’s needs cannot be adequately met by the

environment, the child becomes destabilized. As the increasingly destabilized child

continues to stretch an environment’s ability to respond adequately, further invalidation

ensues, and over time this transaction may lead to the development of a psychopathology.

Research indicates that impulsivity and chronic irritability of the kind exhibited in

children with emotional dysregulation are associated with a range of impairments.

Problematic relationships with parents, siblings, peers, and teachers, persistent

difficulties in multiple settings, and negative feedback may lead to the development of

negative self-concept in affected children, impede their emotional, social, and cognitive

development, and increase chances of psychopathology in adolescence and adulthood

(e.g., personality disorders, substance abuse, mood disorders and suicidality) (Althoff,

Verhulst, Retlew, Hudziak, & Van der Ende, 2010; Okado & Bierman, 2015; Pickles et al.,

2009).

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DBT-C Hierarchy of the Treatment Targets

DBT-C aims to stop the harmful transaction between a child and an environment, and

replace it with an adaptive pattern of responding. The main goal is to reduce the risk of

psychopathology in the future, while intervening to ameliorate presenting problems. The

intervention and prevention are primarily achieved via 1) teaching parents how to create

a validating and change-ready environment; 2) empowering parents to become coaches

for their children to promote adaptive responding during treatment and after therapy is

completed; and 3) teaching children and their parents effective coping and problem-

solving skills.

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 (i.e., life-threatening behaviours, therapy-

interfering behaviours, quality-of-life interfering behaviours, and skills training), DBT-C

includes three main categories, which are subdivided into ten subcategories (see Table 1).

The DBT-C treatment target hierarchy is the same for outpatient, residential, and

inpatient settings. In inpatient and residential settings, milieu and nursing staff share a

caregiving role with parents, and in many ways, these assume more caregiving

responsibility as children spend more time with the staff than with their parents. Thus,

the parent-related treatment targets discussed below apply to all caregivers in contact

with a child.

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Table 1. DBT-C Hierarchy of the treatment targets

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 6. Improve parent-child relationship

III. Target child’s presenting problems 7. Risky, unsafe, and aggressive

behaviors

8. Quality-of-life-interfering problems

9. Skills training

10. Therapy-interfering behaviors of a

child

I. Decreasing the Risk of Psychopathology in Adolescence and

Adulthood

1. Life-Threatening Behaviours of a Child

The primary focus of treatment is to keep a child alive and well. If a child is at risk of

suicide-related behaviours, this target is treated as a priority. The target includes 1)

suicidal acts; 2) non-suicidal self-injury (NSSI); 3) suicidal communications and ideations;

4) suicide-related expectations and beliefs; and 5) suicide-related affect. Pre-adolescent

children with emotional dysregulation are at an increased risk of suicidal behaviours and

ideations and NSSI (Tamás et al., 2007; Holtman et al., 2011). In a study with children

with Disruptive Mood Dysregulation disorder (DMDD), where emotion regulation is seen

as a core dysfunction, more than 50% of children reported suicidality and/or NSSI

(Perepletchikova et al., manuscript in preparation).

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2. Therapy-destroying behaviours of a child

Most of the problematic behaviours a child can exhibit during a treatment session (e.g.,

verbal aggression, threats, cursing, screaming, running around) are addressed with

planned ignoring (i.e., removing attention from undesirable behaviours and immediately

attending to any positive responses). Additionally, these behaviours are treated as

informative (i.e., they help the therapist observe parent-child interactions in the real

time) and target-relevant (i.e., they allow the therapist to model and coach effective

responding methods to parents and a child).

However, there are behaviours that cannot be ignored. Therapy-destroying behaviours

are subdivided into those that occur during a session and those that occur outside a

session. Therapy-destroying behaviours that occur in sessions include physical aggression

to a therapist and/or parent(s), severe destructive behaviours (e.g., trashing therapist’s

office, throwing objects), and running out of a treatment room (unless a child stays right

outside the therapist’s office, when this behaviour can be safely ignored). These

behaviours are dangerous for a child, other people, and property, and have to be

immediately suppressed. If a behaviour can be addressed in any other way instead of

immediate suppression (e.g., ignoring, removing opportunities for behaviour to occur),

then this behaviour is treated as therapy interfering, and not as therapy destroying.

When therapy-destroying behaviours occur in session, parents (not the therapist) can put

a child into a time out, but only if this technique was already covered with parents in

prior sessions and practiced at home. Or, the therapist can end the session with the child

while continuing the session with parent(s) if possible. It is important to keep in mind that

ending a session can reinforce maladaptive behaviours, especially if the child does not

want to continue with a session. This issue is easier to prevent than to resolve. Prevention

efforts may include focusing on developing a strong therapist-child relationship,

promoting the child’s motivation for change, creating a validating environment, and

reinforcing treatment engagement (e.g., praise, tangible rewards). If a dangerous

behaviour still occurs, safety is prioritized.

Out-of-session therapy-destroying behaviours include dangerous levels of aggression to

parents, siblings, peers, and other people, as well as severe property destruction. These

behaviours become therapy destroying when the level of escalation precludes application

of therapeutic techniques due to safety concerns. Aggressive and property-destroying

behaviours can become especially detrimental to conducting effective treatment when

temper outbursts and other undesirable behaviours are put on an extinction schedule.

Extinction bursts, which occur when a response is no longer reinforced, may escalate to a

degree where it is no longer safe to continue to ignore a behaviour. Thus, there is an

increased risk that extinction will be terminated and an escalation of an aggressive

behaviour will be reinforced by attention, removing an unwanted demand, giving in to a

request, granting a covered privilege, etc. For example, a child starts to scream because

her parents refused to grant her request. The parents implement planned ignoring, which

is followed by an anticipated extinction burst. However, for this child, escalation is likely

to quickly reach dangerous levels and may involve running out of the house into traffic,

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attempting to choke a sibling, flipping furniture, breaking windows, etc. At this point

parents are likely to attempt to pacify a child, or call the police, or resort to a

hospitalization. All of these outcomes are highly counterproductive. They reinforce

escalated behaviours, and subsequent attempts to follow an extinction protocol will

become increasingly futile. Thus, it is important to conduct a very thorough assessment of

a child’s level of severity before accepting a family into a treatment to determine if child’s

needs can be addressed on an outpatient level of care. Further, a psychiatric intervention

can be considered to ameliorate reactivity with a psychotropic medication at the

beginning stages of treatment, with a plan to start titrating medications down as soon as

possible. In the randomized clinical trial of DBT-C for children with DMDD, all

improvements were achieved without additional psychopharmacological interventions

(Perepletchikova et al., manuscript in preparation). Although more research is needed,

the results of this study suggest that psychosocial treatment alone without additional

medication management may be sufficient, in most cases, for treatment in outpatient

settings. However, when there is a choice between placing a child in a residential setting

or continuing to address problematic behaviours in an outpatient setting with an addition

of a psychotropic medication, it is advised to attempt the latter first. With all things being

equal, implementation of the most benign treatment possible is important for any

therapeutic approach.

3. Therapy-interfering behaviours of parents and therapists

DBT-C views parental adaptive patterns of responding as key to achieving lasting changes

in a child’s emotional and behavioural regulation. Thus, DBT-C focuses on teaching

parents how to create a validating and change-ready environment for their child in order

to address presenting problems and to reduce risk of psychopathology in the future.

Parents are trained to become coaches for their children, and to continue the intervention

after a treatment ends. Significant and lasting treatment gains cannot be achieved

without parental commitment to treatment, engagement in therapy, and willingness to

follow the agreed-upon plan. Thus, treatment cannot successfully continue if parents

frequently miss sessions, fail to bring a child to treatment, keep re-scheduling

appointments, refuse to take part in therapy, fail to follow therapist’s recommendations,

and continue to use prolonged or harsh punishments or other ineffective parenting

techniques to force a child’s compliance.

Therapists also can engage in therapy-interfering behaviours. DBT for adults and

adolescents highlights a whole range of such behaviours, including a failure to be

dialectical (e.g., imbalance of reciprocal versus irreverent communication) and engaging

in behaviours that are disrespectful to clients (e.g., coming in late, missing appointments,

appearing dishevelled). All of these issues apply to DBT-C therapists as well. However, a

behaviour 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 behavioural escalations may lead to attempts to pacify a child

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in a moment and, thus, a reinforcement of dysfunctional behaviours, as well as modelling

of ineffective problem resolution to parents.

4. Parental emotion regulation

In order for parents to model effective coping and problem solving, ignore maladaptive

responses, validate a child’s suffering, reinforce desirable behaviours, among other

techniques, parents have to be in control of their own emotional reactivity. That is one of

the reasons why, in DBT-C, parents not only learn everything that their child is learning

(e.g., skills and didactics on emotions), but they must also participate in the parent

training component. A DBT-C therapist continues to stress throughout the treatment that

while the child’s emotion regulation is the main target, the main focus in achieving this

goal is parental behaviour, and the therapist also closely monitors parental emotion

regulation and the use of DBT-C skills. At times, this may include advising parents to seek

treatment for their own psychopathology, as well as marriage counselling.

5. Effective parenting techniques

Frequently by the time parents decided to enter treatment with their child, the disruption

in the child-environment system has reached a significant level, and parents are greatly

stressed. Screaming and yelling at a child, as well as excessive, prolonged, and/or

physical punishment are quite common. It is imperative to ensure parental willingness to

employ effective parenting techniques, to rely primarily on validation, reinforcement,

ignoring, and natural consequence, and to use punishment only sparingly and

strategically. The use of effective parenting techniques is paramount to decrease

invalidation, start healing the parent-child relationship, and reduce parental modelling of

dysfunctional behaviours.

Parental behaviours can help ameliorate the child’s emotional dysregulation or can

exacerbate it through the process of the transaction discussed earlier. In DBT-C, whether

an incident was effectively resolved is evaluated primarily by the environmental response.

For example, if a parent responded to a stressful event in an effective way (e.g., stayed

calm, modelled use of skills, validated or ignored as needed) while a child had a two-hour

temper outburst, the situation is considered to have 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 behavioural 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 behaviours are

likely to remain isolated and sporadic incidents. DBT-C indeed upholds that a child’s

behaviour is irrelevant until the environment is able to consistently and effectively

promote progress. Consequently, parental responses are treated as a higher priority than

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the child’s behaviours throughout the duration of treatment. Table 2 presents the list of

topics of the parent training component.

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Table 2. Parent-training curriculum

Pre-treatment phase

Biosocial theory,

transactional

model, and goal

Discussion of the biosocial theory, transactional model, and

the DBT-C hierarchy of treatment targets.

Orientation and

commitment

Discussion of the treatment model and how it will address

specified goals.

Commitment is elicited and required from parents to start

treatment.

Didactics on emotions and problem solving

Didactics on

emotions

Discussion of the following topics: definition of emotions,

function of emotions, myths about emotions, emotions vs

mood, feeling/thought/behaviour triangle, levels of emotional

intensity, Emotions Wave, Behaviour Change Model, Emotion

Regulation Model, radical acceptance, and STOP skill.

Problem solving Discussion of the following topics: four responses to any

problem, pros and cons, cognitive restructuring and five steps

of problem solving.

DBT-C skills

Skills training Mindfulness, distress tolerance, emotion regulation, and

interpersonal effectiveness.

Parent training

Creating a change-

ready environment

Discussion of the following topics: definition of a behaviour,

three steps to behaviour change, main factors that maintain

undesirable behaviours, definition of a problem, five cardinal

rules of parenting, and importance of a positive parent-child

relationship.

Creating a

validating

environment

Discussion of the following topics: definition of validation,

function of validation, levels of validation, what validation is

not, invalidating behaviours, and troubleshooting validation.

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Introduction to

behaviour change

techniques

Discussion of the following topics: definitions of

reinforcement, punishment, extinction, and shaping, and how

to give effective prompts.

Reinforcement Discussion of the following topics: function of reinforcement,

types of reinforcers, factors that enhance the effectiveness of

reinforcement, and using a point chart to reinforce skills use

and other adaptive behaviours.

Punishment Discussion of the following topics: function of punishment,

punishment vs retaliation, punishment vs natural

consequences, side effects of punishment, punishment traps

for caregivers, myths about punishment, factors the enhance

effectiveness of punishment, when and how to use each

punishment technique (reprimands, time out, chores, and

taking away privileges).

A-VCR model of

responding

Putting it all together by using an A-VCR model: Attend/

Assess, Validate, Coach skills use, Reinforce

Introduction to

dialectics

Discussion of the guiding principles of dialectics (there is not

absolute nor relative truth, opposite things can both be true,

change is the only constant, and change is transactional), how

these principles apply to parenting, and ways to practice

dialectics.

Dialectical

dilemmas

Discussion of dialectical dilemmas of parenting: permissive vs

restrictive parenting, overprotective vs neglectful parenting,

overindulging vs depriving parenting, and pathologizing

normative behaviours vs normalizing pathological behaviours.

Walking the middle

path

Discussion on how to walk the middle path by balancing the

opposites and looking for a synthesis, balancing extremes of

parenting styles, searching for what is valid, and using

behavioural principles and effective parenting strategies.

II. Improving the Parent-Child Relationship

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6. Improve Parent-Child Relationship

DBT-C Behaviour Change Model maintains that in order for any behaviour change to

occur, three factors have to be present: 1) awareness of an action urge before an action

occurs; 2) willingness not to follow an action urge if it is not justified by a situation, and

instead respond in an adaptive way; and 3) a capability to engage in an effective

behaviour. A positive parent-child relationship is required for a child to accomplish each

of these tasks successfully.

In order to decrease reactive responding and enhance adaptive functioning, an individual

has to be aware of an action urge before it becomes an action. An action urge is a

directive from our emotions on how to react to a situation. Although emotions are our

main motivators to initiate and sustain behaviours needed to achieve specific goals, they

are, so to speak, blind to whether their directives are justified by a situation. To regulate

our emotions means to be in control of a decision on whether or not to follow an action

urge, given the environmental demands. In other words, an emotion provides the fuel and

direction but cannot be in the driver’s seat. For example, an action urge of fear to run

away from a lion is justified on the open plains of the Serengeti, but not justified when a

lion is in a cage in a zoo.

The awareness of action urges can be gradually enhanced by practicing mindfulness.

Mindfulness means being fully present in the moment, purposefully, and in a non-

judgmental way. Mindfulness is a complicated concept. Adults frequently take a

considerable amount of time to fully appreciate its meaning and function and to start

practicing mindfulness consistently. Therefore, to expect pre-adolescent children to

practice mindfulness without support and encouragement from their families is

unrealistic. However, even if mindfulness practice becomes a daily routine for parents, a

child’s interest and motivation to join in largely depend on the relationship they have with

their parents. For children, mindfulness practice usually involves mindful participation in

games and other activities with family members. If a parent-child relationship is severely

strained, a child is more likely to avoid parents and resist joint activities (Kerns et al.,

2000). The above discussed issues in a strained parent-child relationship, of course, apply

to any skills practice (not just mindfulness) and any parental modelling. Mindfulness

practice is a special, albeit very important, case as mindfulness is a core DBT skill on

which the use of all other skills depends.

Awareness of an emotional reaction and a corresponding action urge are required, but

not sufficient, for a desired response to occur. An individual has to be willing not to follow

an action urge if it is not justified by the demands of a situation. This is difficult,

especially for children with severe emotional sensitivity. The difficulty comes from a need

to somehow harness the willingness to go against our main motivators—our emotions.

Willingness is not the same as acceptance, but it is a first step leading to it. Willingness is

acting as if one has already accepted and is ready for a change. It is starting to walk

towards change and away from a wilful stance; it is exhaling fighting and inhaling

acceptance.

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There are four main sources of willingness—intrinsic motivation, extrinsic motivation,

reciprocity and satisfying functions of the behaviour (Ryan & Deci, 2000). Intrinsic

motivation occurs when the activity itself is rewarding, satisfies our basic needs (e.g.,

food, shelter, companionship) and enhances a sense of pride, self-esteem, self-

determination, interest to learn, and the ability to gain self-mastery and achieve goals.

Extrinsic motivation occurs when an activity is rewarded by incentives not inherent in the

task, such as external attention, accolades, praise and recognition from others, as well as

material rewards, money, or tokens (e.g., stickers, points). The younger the child, the

higher the tendency to be motivated by extrinsic, rather than intrinsic, rewards

(Hayamizu, 1997). Extrinsic rewards that are contingent and tied to performance levels

can over time establish interest in activities that lack initial interest, as well as enhance

effort and persistence, increase perception of self-determination and reliance on intrinsic

motivation to continue achieve desired outcomes (Cameron, Banko, & Pierce, 2001).

Thus, without a strong extrinsic motivational system, any improvements in children’s

behaviour may be isolated and sporadic.

Reciprocity is the middle ground between internal and external motivation. It is a

transaction in which parents and the child share a mutual goal to act in ways to meet

each other’s expectations, satisfy interests, and benefit the relationship. To build

reciprocity, parents need to focus on doing what their child finds enjoyable (playing a

video game) and not what they think may be better for the child (e.g., reading a book).

Reciprocity enhances both internal and external motivation and helps build a positive

parent-child relationship.

Furthermore, parents need to help child understand the function of his/her maladaptive

behaviour and aid in addressing this function in adaptive ways. No amount of skills

training and reinforcement will produce a consistent behaviour if a function is not

satisfied. For example, if a child’s aggression towards a sibling leads to a coveted

parental attention and physical contact (even if this means being restrained to prevent

injury to self and others), showering this child with rewards for using skills may only

produce isolated and sporadic instances of the prosocial behaviour, if the desired

attention and contact are not obtained. Understanding and addressing functions are

imperative to eliciting and sustaining motivation.

Consistent progress can be achieved when an environment is supportive, reinforcing, and

validating. A positive parent-child relationship serves four main functions: 1) modelling a

relationship built on acceptance, trust, reinforcement, shared interests, and mutual

respect; 2) increasing a child’s desire to spend time with parents, which provides parents

with more opportunities to model and prompt skills use, and to offer validation and

reinforcement; 3) increasing a child’s motivation to do desired behaviours to please

parents, make parents proud, and earn rewards; and 4) building pathways in the child’s

brain associated with adaptive functioning. A relationship where parents are punishing,

critical, judgmental, and invalidating not only dysregulates a child and models ineffective

patterns of relating, but may also lead to the child avoiding, distrusting, and retaliating

against the parents (Morris et al., 2002; Strand, 2000). Avoidance and distrust can

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significantly decrease the frequency and quality of reinforcement. If a child avoids

parents, this may greatly limit the amount of time they spend together, and, thus, the

number of opportunities a parent may have to model, prompt, and reinforce the child’s

effective responding. The quality of reinforcement may also be negatively affected, as

children of abusive parents are shown to be less receptive to reinforcement (Strand,

2000). Retaliation against parents is also quite common when the parent-child

relationship is severely strained. One function of a child’s negative behaviour may be an

attempt to inflict upon the parent the same feelings of ‘misery’ that the child feels by

being pervasively invalidated. When this function predominates, it is unlikely that

reinforcement and skills training will produce a desired behaviour change. This is

because the main goal of reinforcement and skills training is to increase the frequency of

positive and prosocial behaviours, which contradicts the goal of inflicting misery.

Additionally, retaliation (e.g., screaming, yelling and inflicting pain) can be modelled by

parents as a way to respond to problems. Unfortunately, retaliation is frequently confused

with punishment. The function of punishment is to suppress an undesirable behaviour in

a moment. Punishment, as a behaviour modification technique, should be applied

consistently and strategically (e.g., in DBT-C it is only used to suppress unsafe

behaviours, such as physical aggression). The function of retaliation, on the other hand, is

to inflict suffering in a response to an aversive event. Retaliation is used inconsistently

and indiscriminately because it is a mood-dependent response. While punishment targets

a suppression of another person’s dysfunctional behaviour, retaliation targets a decrease

of one’s own aversive emotional state. A parent-child relationship where mutual

retaliation is frequent will continue to exacerbate the pattern of invalidation and, thus,

decrease child’s willingness to engage in adaptive behaviours.

Awareness and willingness are only instrumental when an individual has a behavioural

capability to act in an effective way. Behavioural capability is achieved via learning and

practicing adaptive skills. Learning is initiated during treatment sessions. However, most

of the work on the application of the techniques occurs outside of the office. Parents are

entrusted with eliciting further discussions of the concepts, practicing techniques, and,

most importantly, demonstrating the use of skills via modelling. Skills can be practiced

with children in four main ways, such as: 1) during an actual problematic situation; 2)

while processing a problematic response after an outburst has occurred and rehearsing

alternative solutions; 3) during the practice of skills in hypothetical problematic

situations via role-plays; and 4) while coping ahead of problematic situations that are

likely to happen in a near future and deciding on how to respond. All four situations

necessitate parental participation. The first scenario requires parental attention to

prompt, refine, and reinforce adaptive responding, while the last three are primarily

elicited by parents.

In DBT-C, parental modelling of skills use is seen as one of the most important ingredients

of change. A child’s adaptive responding cannot be expected if the environment is

consistently reacting in dysfunctional ways, and is not promoting the child’s learning by

demonstrating skilful behaviours. Developmental psychologists have always maintained

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that children learn by imitating adults (Bandura & Kupers, 1964). The importance of

modelling for behaviour acquisition has been championed by Albert Bandura and his

famous Bobo doll experiment (Bandura, Ross, & Ross, 1961). Bandura’s social learning

theory postulated that behaviours are learned through the environment by observing,

encoding, and imitating modelled responses (1977). More recent research actually

indicates that children will imitate everything that adults demonstrate, including actions

that are obviously irrelevant (something other primates do not do) (Horner & Whiten,

2005; Nielsen, 2006). It appears that children assume that all actions demonstrated by

adults have a purpose (even if unknown), have been tested and presumed rational, and

are attempts to transmit knowledge (Gergely & Csibra, 2005, Gergely, Egyed, & Kiraly,

2007). Indeed, our motivation to do things like those around us may be a universal human

activity and may be the way that human culture is transmitted (Nielsen & Tomaselli,

2010).

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III. Targeting the Child’s Presenting Problems

7. Risky or Unsafe Behaviours

Emotional dysregulation is often associated with aggression toward other people (Okado

& Bierman, 2015; Roy et al., 2013). Aggressive behaviours can be high risk and can

sometimes result in injury or destruction of property. Yet, they are lower on the hierarchy

than parental behaviours because addressing them without first targeting changes in the

environment is not likely to produce lasting results. Aggression towards others can be

divided into four main categories: 1) physical aggression (e.g., kicking, punching,

throwing objects with an intend to hit a person, scratching, spitting, pulling hair); 2)

verbal aggression (e.g., screaming, yelling, threatening; duration is for longer than one

minute); 3) destructive behaviours (e.g., breaking objects, ripping paper, throwing objects

without an intent to hit a person); and 4) talking back (e.g., swearing, “smart aleck”

comments, name calling; duration is one minute or less).

The risky or unsafe behaviours category includes any behaviours that threaten the safety

of other people or property, and thus, cannot be ignored. These usually include physical

aggression and destructive behaviours. These behaviours are not dangerous enough to be

included into the therapy destroying category, as they are mild to moderate in severity

and are not likely to cause significant damage to child, other people or property, or

severely disrupt a treatment process.

DBT-C teaches parents to rely almost exclusively on modelling, acceptance, validation,

reinforcement, ignoring, and natural consequences. Punishment techniques (i.e.,

reprimands, time out, assignment of chores, and removal of privileges as a back-up

strategy) are used primarily to suppress behaviours that cannot be ignored because they

are a safety risk (e.g. a child is throwing objects at her sibling). Punishment procedures

are always supported by the reinforcement of desired alternative responses and shaping

programs (i.e., reinforcement of the successive approximation of a response in order to

produce a final desired behaviour). Parents are made explicitly aware that, even in

circumstances when a behaviour has to be suppressed, short-term gains are achieved at

the expense of long-term outcomes, as punishment is associated with a slew of

detrimental side effects (e.g., emotional escalation, modelling force as a conflict

resolution strategy, reinforcement of unwanted behaviours by attention, straining the

parent-child relationship, and consequent avoidance of parents) (Strand, 2000). Although

DBT-C supports zero tolerance of physical aggression and destructive behaviours and

teaches parents punishment techniques, the emphasis is on the reinforcement, shaping,

and learning skills. Thus, it is easy to appreciate why parental behaviours are given a

priority even over the child’s physical aggression, as effective punishment, reinforcement,

and skills practice will not occur without first addressing parental capabilities.

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8. Quality-of-life-interfering problems

The quality-of-life-interfering problems include child and environmental issues that

interfere with a child’s functioning. These may include a child’s behaviours (e.g., verbal

aggression, severe interpersonal problems) and co-morbid psychiatric disorders, as well

as insufficient environmental supports (e.g., school services) (see Table 3). Although

physical aggression can also be viewed as a quality-of-life-interfering behaviour, it is

separated into its own category to ensure that it is treated as a higher priority, and is

therefore targeted before other quality-of-life (QoL) issues are addressed. For example, it

is advisable to implement a shaping program to reduce verbal aggression only after

physical aggression is eliminated. Implementation of multiple reinforcement and shaping

programs is undesirable and counterproductive, as a child may have too many venues to

earn rewards. Goals that are higher on the target hierarchy are usually more difficult to

attain. If a child receives a sufficient number of points and rewards for behaviours that

are lower on a target hierarchy (e.g., completing chores, doing homework), it may

decrease a child’s motivation to work on higher-level targets (cutting, physical

aggression).

Issues that do not qualify as interfering with QoL are usually not extensively addressed

during therapy and are instead left for parents to continue to resolve once treatment is

completed. However, therapists have to be prepared that parents may have strong

opinions on what is a priority and will expect therapist to address most of their preferred

targets (e.g., academic achievements, attending extracurricular activities) during the

treatment. Additionally, parents may have difficulty agreeing with a need to change their

own behaviours and may especially find it problematic to accept a notion that their

behaviours take precedence over their child’s behaviours. Therefore, parents’ orientation

to the biosocial theory, transactional model, and a treatment target hierarchy and

commitment to the model are prerequisites to initiating treatment, while a child’s

commitment is not required. Given that it is not always possible to address all of the

concerns parents have regarding child’s functioning during the treatment, it is always

helpful for parents to understand that they will be taught techniques that can be used to

develop any child behaviours that are desired, but that are not yet fully established at

treatment completion.

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Table 3. Pre-adolescent children quality-of-life-interfering behaviours.

1. Co-morbid Axis I disorders (e.g., ADHD, anxiety, depression)

2. Neurophysiological problems (e.g., sensory processing disorder)

3. Verbal aggression (e.g., screaming, yelling, threatening for longer than one

min.)

4. Talking back (e.g., cursing, smart-alec comments, dismissive or disrespectful

responses for ≤ one min.)

5. Issues with delayed gratification and impulse control behaviours (e.g., stealing,

lying, cheating)

6. Severe interpersonal difficulties with siblings, peers, teaching, family members

(other than primary caregivers)

7. Parent/family issues (e.g., child’s response to parental divorce)

8. School problems (e.g., school refusal, detentions, suspensions, difficulties with

homework)

9. Need for further services (e.g., special services at school, occupational therapy)

10. Problems with maintaining physical health (e.g., refusing to take prescribed

medication, refusing to go to medical appointments)

9. Skills Training

As discussed above, in order for a change to occur, an individual has to have behavioural

capabilities. DBT-C requires the skills training curriculum to be completed by children as

well as their parents. At least one parent has to attend treatment sessions consistently to

learn the material, with a goal of communicating this learning to other caregivers (e.g.,

the other parent, grandparents, babysitters). DBT-C incorporates almost all of the adult

DBT skills into the curriculum, with some exceptions that may not be developmentally

appropriate for pre-adolescent children (e.g., finding meaning, sticking to values, no

apologies; see Table 4). In DBT-C, “skills” is a general term that encompasses all of the

didactic material taught during individual therapy (see Table 5) and skills training (see

Table 6). Topics are taught in the sequence presented, and further discussion about

treatment structure is discussed in Section 3).

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Table 4. DBT for adults skills vs DBT for children skills.

DBT adult skills DBT-C skills DBT-C individual Parent training Not covered

Mindfulness

Three states of mind Three states of mind

What skills What skills

How skills How skills

Interpersonal effectiveness

Factors reducing

Interpersonal

Effectiveness

What gets in the way of

being effective

Myths Worry thoughts

Cheerleading Cheerleading

DEAR DEAR

MAN, GIVE, FAST FRIEND (no) Apologies

Stick to values

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Walking the middle

path

Walking the middle

path

Dialectics Dialectics

Validation Validation

Behavior change skills Behavior change skills

Distress tolerance

STOP STOP

Wise mind ACCEPTS

IMPROVE the moment

TIP skills

DISTRACT Self-reinforcement

Self-validation

Comparisons

Meaning

Prayer

Self-soothe Self-soothe

Pros and cons Pros and cons

Radical acceptance Letting it go

Willingness/willfulness Willingness/willfulness

Emotion regulation

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Understanding

emotions

What am I feeling?

Feeling thermometer

Feeling/thought/

behaviour triangle

Myths about emotions Myths about emotions

Model for describing

emotions

Emotion Wave

What good are

emotions?

Why emotions are

important?

Letting go of emotional

suffering

Surfing Your Emotions

Check the facts Check the facts

Problem solving Problem solving

Opposite action Opposite action

PLEASE PLEASE

ABC LAUGH

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Table 5. Individual counseling curriculum

Pre-treatment phase

Biosocial model

and treatment

goals

Discussion of emotional sensitivity, invalidating environment,

and resulting problems.

Long-term and short-term goals are discussed and an “Eiffel

Tower” of the child’s own treatment target hierarchy is

created.

Orientation and

commitment

Discussion of the treatment model and how it will address

specified goals.

Commitment is elicited (only if therapist is confident that a

child is willing and likely to commit.

Didactics on emotions

What am I feeling? Discussion of emotions, corresponding sensations and action

urges, changes in face and body.

Feelings/thought/

behaviour triangle

Discussion of how feelings, thoughts, and behaviours are

different, how emotions can be turned into mood, and how

emotions have different levels of intensity (as a “Feeling

Thermometer”).

Why are emotions

important?

Discussion of the functions of emotions and myths about

emotions.

Emotion Wave Emotion Wave is seen as going through six stages: event,

thought, feeling, action urge, action, and after effect.

Food for emotions Discussion of three sources of food for emotions: doing what

emotion wants, thinking what emotions wants, and maintaining

tension in the body that emotion brings

Behavior change

model

Three main factors that are needed to change your own

behaviour: awareness, willingness and capability.

Willfulness and

willingness

Being willing to accept reality as it is as opposed to being

willful in refusing to do what works.

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Letting it go Techniques for accepting events that cannot be changed with

mind and body.

STOP skill Avoiding impulsive reactions using STOP skills: Stop and do not

move a muscle, Take a step back and breathe, Observe what is

going on inside and outside of you to collect information,

Proceed mindfully by considering goals.

Individual therapy following stage 1 targets

Four responses to

any problem

Solve a problem, change the way you feel, tolerate and accept,

stay miserable.

Short-term and

long-term

Pros and cons

To select an effective solution to a problem, consider pros and

cons of each response, and note which consequences are short

term and long term.

Check the facts Cognitive restructuring by catching ineffective cognitions,

challenging, and changing them.

Problem solving Five steps to problem solving: describe the situation, consider

the “Eiffel Tower of Goals,” brainstorm all possible solutions,

choose on that fits bets, act on your choice, and note results to

consider next time.

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Table 6. DBT-C skills training curriculum

Mindfulness

Introduction Meaning, importance, and goals of mindfulness skills.

What is

mindfulness?

Paying attention to paying attention on purpose, in this one

moment, and non-judgmentally

Three states of

mind

“Emotion mind” is when thoughts and behaviours are controlled

mostly by emotions and it is hard to think straight.

“Reasonable mind” is when thoughts and behaviours are controlled

by logic and rules and emotions are not considered.

“Wise mind” is a when we take into account information from our

feelings and thoughts and add intuition when making decisions.

Steps to connect to Wise mind are discussed.

What skills Observing, describing, and participating with awareness.

How skills Don’t judge, stay focused, and do what works.

Review Review and discussion of the learned mindfulness skills.

Distress tolerance

Introduction Meaning and goals of distress tolerance skills.

DISTRACT Controlling emotional and behavioral responses in distress using

DISTRACT skills: Do something else, Imagine pleasant events, Stop

thinking about it, Think about something else, Remind yourself

that feelings change, Ask others for help, Contribute, Take a break

and Tense and Relax.

TIP When at a breaking point, use TIP skills: Tense and Relax, Intense

sensation, Paced Breathing

Self-soothe Tolerating distress by using the five senses: vision, hearing, taste,

smell, and touch.

Review Review and discussion of the learned distress tolerance skills.

Emotion regulation

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Introduction Meaning and goals of emotion regulation.

Surfing your

emotion

Decreasing the intensity of emotional arousal by attending to

sensations the emotion produces in the body without distracting or

ruminating.

Opposite

action

Changing emotion by acting opposite to the action urge.

PLEASE skills Reducing emotional vulnerability with PLEASE skills: attend to

PhysicaL health, Eat healthy, Avoid drugs/alcohol, Sleep well, and

Exercise.

LAUGH skills Increasing positive emotions with LAUGH skills: Let go of worries,

Apply yourself, Use coping skills ahead of time, set Goals, and

Have fun.

Review Review and discussion of the learned emotion regulation skills.

Interpersonal effectiveness

Introduction Meaning and goals of interpersonal effectiveness.

Worry

thoughts &

cheerleading

Goals of interpersonal effectiveness, what gets in the way of being

effective and cheerleading statements.

Goals Two kinds of interpersonal goals, “getting what you want” and

“getting along.”

DEAR skills How to “get what you want” using DEAR skills: Describe the

situation, Express feelings and thoughts, Ask for what you want,

Reward or motivate the person for doing what you want.

FRIEND skills How to “get along” by using the FRIEND skill: (be) Fair, Respect

the other person, (act) Interested, Easy manner, Negotiate and (be)

Direct.

Review Review and discussion of the learned interpersonal effectiveness

skills.

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10. Therapy-Interfering Behaviours of the Child

DBT-C is quite tolerant of child behaviour 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 behaviours (verbal aggression,

threats, cursing, screaming, using threatening body language, devaluing treatment as a

waste of time, running around, and other distracting behaviours) are just ignored with a

plan to help a child re-regulate and re-focus attention when appropriate. If such

behaviours occur consistently, they are targeted by a shaping program.

Furthermore, problematic behaviours that occur during sessions, such as temper

outbursts, can be very informative and target relevant, as 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

behaviours in session also helps with extinction generalization (e.g., swearing is not

attended to at home and in therapy).

If DBT-C is conducted in a residential setting or inpatient units, skills training is usually

delivered in groups and parents are not present. However, ignoring the above-described

behaviours is still practiced to the fullest extent possible. For other participants, a temper

outburst of a group peer (unless a behaviour is aggressive or dangerous) is viewed as an

opportunity to practice ignoring, distress tolerance, and other skills.

Attempts to correct therapy-interfering behaviours as they are occurring during a session

via discussions, behaviour analysis, suppression of behaviours via punishment (except if

dangerous), etc., can reinforce these behaviours 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.

For example, in a situation when a child will only attend therapy if allowed to play on his

iPhone during a session, instead of wrestling over electronic devices, this behaviour is

ignored, and engagement is prompted and reinforced, while a therapist is teaching skills

to parents. Similarly, if a child is very hyperactive and keeps moving and exploring

objects in a room, focusing on having him sit quietly in one place will not be productive.

In such situations, a therapist continues to teach and ask the child questions to assess

attention and comprehension, as well as to engage the child in task-relevant activities.

A child’s therapy-interfering behaviours are addressed primarily via 1) developing a

strong therapist-child relationship; 2) reinforcing desired behaviours in the moment and

shaping adaptive responding over time; 3) ignoring problematic behaviours (except if

dangerous); 4) relying on natural consequences (i.e., a child does not get a participation

reward); 5) conducting a chain and solution analysis of a behaviour in subsequent

sessions; and 6) if child is not engaging, teaching the material to parents with the goal for

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them to communicate this material to a child at home via modelling, discussions, and

prompting, reinforcing, and practicing skills use.

Overview of adaptations

DBT-C adaptations to therapeutic strategies, skills training, and individual treatment, as

well as the parent-training component have been discussed elsewhere (Perepletchikova et

al., 2011; Perepletchikova & Goodman, 2014). Therefore, they will only be briefly

reviewed in this section. DBT-C retains all principles, therapeutic strategies, didactic

information, and skills modules of DBT for adults (Linehan, 1993, 2015). However,

significant deviations from the original DBT permeate the entire DBT-C model, starting

with how the presenting problem is discussed with children and their families. In working

with this population, clinicians have to ensure that the terms “sensitive” does not

continue to be associated with a child being touchy, defensive, uptight, paranoid, or

neurotic. To aid this goal, the term “supersenser” may be used as a better descriptor. This

word was derived from terms describing people with heightened sensitivity to sensory

perceptions. Indeed, there are those who have an increased number of taste buds and

experience the sense of taste with far greater intensity than an average person; these

people are referred to as supertasters (Hayes & Keast, 2011). There are also

supersmellers who have an increased olfactory acuity that causes them to have a lower

threshold for odour, or hyperosmia (Hummel, Landis, & Huttenbrink, 2011). Having

“super” abilities may present with some advantages as it allows such people to appreciate

the nuances of tastes and smells to a greater extent; however, the intensity of their

experiences can be overwhelming. Similarly, those who have a lower threshold for

emotional arousal and experience it with greater intensity and duration than an average

person may be referred to as supersensers. Just like the others with “super” abilities,

supersensers can be easily overpowered by their reactions; however, their abilities may

have some advantages. Research and clinical practice indicate that these people are not

only sensitive to their own emotions, but also may be more attuned to other people’s

emotional states and may be very empathic (see, e.g., Spinrad & Stifter, 2006; Zahn-

Waxler, Robinson, & Emde, 1992). Perhaps people who are reactive themselves have an

enhanced understanding and concern about another person’s distress. Explaining the

notions of emotional sensitivity from a perspective of supersensers’ special abilities and

challenges rather than a vulnerability can achieve multiple functions. It may help avoid

the risk of invalidation, provide a dialectical view of the presenting issue, and in many

cases, give children and their parents a sense of relief and even contentment.

Furthermore, a child’s interest and willingness to learn techniques can be greatly

enhanced when s/he understand that emotional sensitivity is a special ability that needs

to be better controlled, rather than a problem to be corrected.

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DBT-C maintains emotion dysregulation as its main target. In DBT-C concepts are

simplified to promote better comprehension, given the developmental level of the target

population. For example, DBT-C Emotion Change Model discusses emotion regulation as

“not feeding” an unwanted emotion. Children are taught that emotions have three main

sources of food: 1) doing what an emotion is saying to do (i.e., following an action urge);

2) thinking what an emotion is saying to think (e.g., rumination about a triggering event);

and 3) maintaining tension in the body that is associated with emotional arousal. So, if an

action urge is not justified by a situational demand, in order for an emotion to subside or

change, all three sources of “food” have to be interrupted. Emotion regulation skills, such

as “Surfing Your Emotion” and “Opposite Action,” can change an emotional experience

because they include techniques that interrupt all three sources of “food” for an emotion.

For example, “Surfing Your Emotion” skill 1) interrupts action by performing a skill

instead of a dysfunctional behaviour, 2) interrupts rumination by re-orienting attention

from thoughts to sensations in the body that are associated with an emotion (e.g.,

“butterflies in the stomach” for fear), and 3) releases tension by doing half smile and

willing hands. Most of the distress tolerance skills, on the other hand, are designed to

tolerate a situation without making it worse and not to change an emotional experience,

as they usually interrupt just one or two of the “food” sources (e.g., “Do Something Else”

skill interrupts dysfunctional actions, and the “Tense and Release” skill interrupts a

dysfunctional action and releases tension). Figure 1 presents the Emotion Change Model

within the context of the Behaviour Change Model.

DBT-C aims to improve

emotion regulation

through intervening into

each step of the Emotion

Wave paradigm that is

taught to participants

(Figure 2: Step 0)

vulnerabilities or events

that increase chances of a

dysfunctional response

occurring, targeted

through mindfulness and

problem-solving; Step 1)

an event, which can be

internal (e.g., thought, memory, another feeling) or external (e.g., being called names, not

getting a coveted item) is targeted through teaching effective problem-solving and

conducting exposure; Step 2) a thought or interpretation of an event is targeted through

mindfulness and cognitive restructuring; Step 3) physical feeling or sensations in the

body is targeted through mindfulness; Step 4) an action urge or a directive from an

emotion on how to respond to an event (e.g., pushing or kicking for anger) is targeted

through mindfulness; Step 5) an action, whether or not to follow an action urge, is

targeted through skills training and teaching effective problem-solving; and Step 6) the

Click to view larger

Figure 1. DBT-C Emotion Change Model within the

context of the Behavior Change Model.

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after-effects or consequences of an action (e.g., being rewarded or punished, other

thoughts or emotions) are targeted through implementing and teaching contingency

management procedures.

DBT-C favours practices,

experiential exercises,

role-plays, and games to

didactic presentations and

lengthy intellectual

discussions. Active

learning (through

experiencing or practicing

a technique) is preferred

to passive learning

(through reading and

discussing) for several

reasons: 1) to help engage

and sustain children’s

attention; 2) to promote

understanding of the

discussed skills; and 3) to

allow the therapist to

directly observe the use of a technique and provide immediate feedback to further refine

skills use. Experiential exercises help participants experience aspects of the presented

skills and may greatly aid in the understanding of techniques. For example, asking a child

to balance a peacock feather on a tip of her finger will require a mindful participation in

order to keep the feather from falling, thus eliciting an experience of mindfulness. In-

session practice is also used to enhance understanding of techniques, as well as to help

refine skills use. Practices follow the presentation of didactic materials and include the

therapist’s modelling of a skill, eliciting the child’s performance of a skill, and providing

corrective feedback. Role plays give a child an opportunity to practice skills in a playful

way and to apply techniques to real-life situations.

During individual sessions, therapists address specific concerns, review Diary Cards,

perform behavioural analyses, exposure, and cognitive restructuring, provide contingency

management, and help the child apply learned skills to everyday problems. During the

first several individual sessions of DBT-C, the child and caregivers receive didactic

instructions on emotions. The child also learns problem-solving and cognitive

restructuring techniques. Information taught during skills training is simplified and

condensed from DBT for adults. For example, “Wise Mind ACCEPTS,” “IMPROVE the

moment” and “TIP” skills were combined into one skill: “DISTRACT” (see Table 5). DBT-C

skills training is also augmented by multimedia and games. Multimedia presentations

utilize video clips with cartoon characters performing skills effectively or ineffectively,

which helps engage children in a discussion of techniques. Several games also have been

developed for DBT-C. The “Skills Master” card game was created to assist with review of

Click to view larger

Figure 2. Emotions Wave and targets for

intervention.

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the learned skills at the end of each skill module. The “Three-Headed Dragon” game was

developed to assist with chain and solution analysis. Additionally, a parent-training

component has been added to the model, with some strategies adapted from Kazdin

(2005). Parents are required to learn everything their child is learning (i.e., didactics on

emotions and DBT-C skills), and participate in the parent training (i.e., validation,

creation of change-ready environment, behaviour modification techniques, and dialectics

of parenting).

Therapy structure largely depends on organizational demands and family needs. For

example, on an outpatient basis, all treatment components are provided individually to

family units. Children and their parents are seen once weekly for 90 minute sessions (30

min for individual child therapy, 20 min for individual parent component, and 40 min for

skills training with a child and a parent together). A substantial difference in the

developmental levels between seven-year-old and twelve-year-old children can make it

quite a challenge to conduct effective skills training in a group format on an outpatient

level of care. In residential care facilities, on the other hand, children and parents

participate in separate skills trainings. Also, children are typically housed by age which

allows a natural opportunity to conduct group skills training by units.

DBT highlights function over form. DBT-C does not prescribe a specific form for

implementing treatment components, but rather emphasizes adherence to DBT principles

and strategies, which enhances the flexibility of implementation. For example, didactics

on emotions and DBT-C skills are usually taught to children together with their parents.

However, separate training can be conducted when a parent-child relationship is so

strained that a child becomes extremely reactive in his parents’ presence, and where that

reactivity interferes with learning. Separate trainings continue to be conducted until the

relationship sufficiently improves to allow joint sessions.

Empirical support

Two randomized clinical trials were recently completed on DBT for pre-adolescent

children (seven to 12 years of age). The outpatient setting trial targeted children with

DMDD Perepletchikova et al., manuscript in preparation). More than half of these

children reported suicidality and/or non-suicidal self-injury (NSSI), with Attention Deficit

Hyperactivity Disorder (ADHD) and Anxiety Disorders being the most prevalent co-

morbid conditions. 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. Differences between groups were

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shown for both mood symptoms and behaviour outbursts. Observed changes were also

clinically significant and maintained at three-month follow-up.

The residential care trial was completed with male children with a range of psychiatric

conditions, with ADHD, Disruptive Behaviour Disorders and Anxiety Disorders being most

prevalent (Perepletchikova et al., manuscript in preparation). Most children had three or

more co-morbid disorders, and reported suicidality and/or NSSI. The mean IQ for

participants was 88.9. The results of this trial indicated no significant differences in the

attendance and dropout rates between groups, which was expected given the nature of

the residential setting programme. However, significant differences were observed on the

main measures of outcome—the Child Behaviour Checklist (CBCL) and the 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 were

maintained at follow-up, and observed changes were clinically significant.

Significant differences between groups were reported on the CBCL only by the milieu

staff, and not by teachers or parents. One of the factors that may have contributed to the

disparity in the results was the degree to which these caregivers received DBT-C training.

Teachers were not trained in DBT-C, and the same teachers were in contact with both

groups of children. Parents unfortunately attended only a fraction of parent training

groups in both conditions and, thus, also did not receive sufficient training. DBT-C milieu

staff, on the other hand, received intensive training in the DBT-C strategies, coping skills,

didactics on emotions, and the parent-training component, and were supervised weekly

on the application of the techniques. As noted, the goal of caregiver training is to help

create a validating and change-ready environment with the expectation that this will

facilitate children’s progress. Indeed, results of both studies indicated significant and

rapid symptom reduction for children receiving DBT-C within the trained environment.

More research is needed to further examine the caregivers’ role in treatment and to

evaluate the efficacy of DBT for children; however, the obtained results are promising and

provide preliminary support for the model.

Conclusion

DBT for pre-adolescent children retained the theoretical model, principles, and

therapeutic strategies of standard DBT. DBT-C 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. One of the major departures from the original

model is the treatment target hierarchy, which has been greatly expanded to incorporate

DBT-C’s emphasis on the parental role in attaining child’s treatment goals. DBT-C views

parental adaptive pattern of responding as key to achieving lasting changes in a child’s

emotional and behavioural regulation.

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Notes:

( ) DBT-C Behaviour Change Model discusses factors that have to be present to change

one’s own behaviour. A behaviour can be changed without person’s awareness through

shaping and reinforcement.

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Francheska Perepletchikova

Francheska Perepletchikova, Assistant Clinical Professor of Psychiatry, Yale

University