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Continuing Education Credit Information Dialectical Behavior Therapy for Pre-Adolescent Children

With Severe Emotional and Behavioral Dysregulation Live Webinar | October 15, 2015

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Information about the Instructors Francheska Perepletchikova, PhD is an Assistant Professor of Psychology in Psychiatry, Child and Adolescent Psychiatry Division, Weill Cornell Medical College, and Assistant Clinical Professor of Psychology, Yale University School of Medicine. Dr. Perepletchikova has extensive experience in psychotherapy with adults, adolescents and children with severe affective instability, disruptive behavior problems, trauma-related psychopathology, depression, suicidality and self-harm behaviors. Dr. Perepletchikova has a long-standing interest in child development and psychopathology. After completing her B.A. degree at St. John's University and graduating with gold medal for the highest academic average, Dr. Perepletchikova received graduate training in two disciplines, developmental and clinical psychology. She obtained 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 James B. Grossman Best Dissertation Prize. During her internship and post-doctoral training at Yale University School of Medicine, Dr. Perepletchikova gained expertise in Dialectical Behavior Therapy (DBT). She obtained intensive and advanced intensive trainings in DBT with Marsha Linehan's Behavioral Tech. Further, Dr. Perepletchikova have been established as able to deliver DBT with adherence and calibrated as a reliable DBT adherence rater by Behavioral Research and Therapy Clinics at the University of Washington. She also has extensive training and experience in Parent Management Training, Cognitive Behavior Therapy for adults and children, and Trauma-Focused Cognitive-Behavior Therapy for children. Dr. Perepletchikova's current research focuses on adapting Dialectical Behavior Therapy to pre-adolescent children with severe emotional and behavioral dysregulation. This line of research has been funded by the NRSA/NIMH Research Fellowship in Functional Disabilities Interventions, NIMH K99/R00 Path to Independence Career Development Award and a grant from the Green Chimneys Residential Care Treatment Facility. *Faculty Disclosure Statement: Francheska Perepletchikova, PhD is a contracted trainer with Behavioral Tech, LLC and receives compensation for her training activities.

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Dialectical Behavior Therapy for Pre-Adolescent Children with Severe Emotional and Behavioral Dysregulation

Live Webinar | October 15, 2015 | Francheska Perepletchikova, PhD

© 2015 Francheska Perepletchikova, PhD | Distributed by Behavioral Tech, LLC | For educational use only. Do not copy or distribute without permission.Behavioral Tech, LLC | 1107 NE 45th Street, Suite 230, Seattle, WA 98105 | Ph. (206) 675-8588 | Fax 1-(206) 675-8590 | www.behavioraltech.org

Dialectical Behavior Therapy for Pre‐Adolescent Children with Severe

Emotional and Behavioral Dysregulation

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Visit www.behavioraltech.org for all training details.

Dialectical Behavior Therapy for Pre‐Adolescent Children with Severe Emotional and Behavioral Dysregulation

Presenter: Francheska Perepletchikova, PhD

Presenter Introduction

©2015 Francheska Perepletchikova, PhD | Distributed by Behavioral Tech, LLC 5

Dialectical Behavior Therapy forPre-Adolescent Children with Severe

Emotional and Behavioral Dysregulation

Live Webinar | October 15, 2015

Francheska Perepletchikova, PhDAssistant Professor of Psychology

Weill Cornell Medical College


Acknowledgements • Yale School of Medicine

– Seth Axelrod – Lawrence Scahill– Joan Kaufman– Tami Frankforter– Heather Douglas-Palumberi

• Weill Cornell Medical College– John Walkup – Donald Nathanson– Barbara Flye– Caitlin Merrill – Amy Walker – Kelly Zbojovsky– Melissa Kivell

• Green Chimneys Residential Treatment Center– Steven Klee– Jay Davidowitz– Meagan McArthur– Denise Luft– Andrea Furgala– Jessica DeBiase– Kate Schiff– Shannon Shaw– Bethany Burrows– Joanna Becker– Jennifer Yedlin– Christina Henriquez– Carol Pinckney

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Overview• DBT for children adaptations

- Individual - Skills training- Parent training

• Current research- DBT-C for children with DMDD1. Study Design2. Sample Characteristics3. RCT Primary and Secondary Outcomes

- DBT-C for children in residential care1. Study Design2. Sample Characteristics3. RCT Primary and Secondary Outcomes


DBT-C: ADAPTING INDIVIDUAL THERAPY


DBT-C: Adaptations to individual therapy

• DBT principles and theoretical framework were retained without modification

• Session format was modified:

Pre-treatment phase:

Session 1. Biosocial model and goals

Session 2. Orientation and commitment

Treatment Phase:

Sessions 1-5. Didactics about emotions (e.g., what are emotions, why they are important, function of emotions, emotion wave)

Sessions 6-24. Individual therapy following Stage I targets

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Emotion, Thought and Behavior Triangle

What is a difference between an emotion, a thought and a behavior?

Handout 5

Thought

Emotion Behavior

Directions: In the bold sentences: circle an emotion, put a straight line under the thought and put a wavy line under behavior

Chris lost his book report. He got frustrated, thought that he should be more organized and wrote the book report all over again.


2. Thoughts:•How we think about the event

1. Event: •Something happens that gets the feeling started

6. After Effects:•Memories•Thoughts•Body•Behavior•Other emotions

EMOTION WAVEHandout 8

5. Action:•With words•With behaviors

4. Action Urge:Feelings makes us want do something

3. Feelings:•Emotional reactions•Change in face and body


MINDFULNESSHandout 16

STOP skills

Stop Do not just react. Stop! Freeze! Do not move a muscle! Your emotions will try to make you act without thinking. Stay in control!

Take a step back Take a step back from the situation. Get unstuck from what is going on. Let go. Take a deep breath. Do not let your feelings put you over the edge and make you act impulsively.

Observe Take a notice of what is going on inside and outside of yourself. What is the situation? What are your thoughts and feelings? What are others saying or doing?

Proceed mindfully Act with awareness. In deciding what to do, consider your thoughts and feelings, the situation, and the thoughts and feelings of other people. Think about your goals. What do you want to get from this situation? Which actions will make it better or worse?

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DBT-C: ADAPTING SKILLS TRAINING


The Core Skill: Mindfulness

Mindfulness means paying attention in a particular

way: on purpose, in the present moment, and

nonjudgmentally.

‐Jon Kabot‐Zinn


Mindfulness: Three States of Mind

States of Mind

ReasonableMind

WiseMind

EmotionalMind

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Mindfulness: • What Skills

– Observe: just notice

– Describe: put into words

– Participate: enter into the experience

• How Skills– Non-judgmental stance: “just the facts”

– One-Mindfully: in-the-moment

– Effectiveness: focus on what works


Distress ToleranceSkills taught in DT module are to survive/tolerate/get through difficult situations without making things worse

• Willingness and Willfulness– Being willing to accept reality as it is as opposed to being willful in refusing

to tolerate distress.

• DISTRACT – Controlling emotional and behavioral responses to just get through the

situation without making it worse– e.g., watch a movie, help someone else, hold ice

• Self-Soothe– Tolerating distress by using five senses– e.g., put on scented lotion, eat comfort food

• Letting It Go– Accepting things as they are

• Pros and Cons– The positive and negative consequences of engaging and not engaging in a

behavior


Emotion RegulationSkills taught in ER module are to reduce emotional vulnerability by reducing emotional sensitivity, increasing positive emotions, being mindful of painful emotions, instead of fighting them and acting opposite to emotion action urges.

• Surfing You Emotions– Regulating emotional arousal by just attending to an emotion without trying

to change its intensity.

• Opposite Action – Changing affective reaction by acting opposite to the emotion.

• 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, set Goals, and Have fun.

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Interpersonal Effectiveness

Skills taught in IE module are to maximize chances of person getting what she wants, while maintaining or enhancing relationships

• Worry Thoughts and Cheerleading– What gets in the way of being effective and cheerleading statements.

• Two kinds of IE Goals – Two kinds of interpersonal goals, “getting what you want” and “getting along.”

• DEAR skill– 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.

• FRIEND skill– How to “get along” by using the FRIEND skill: be Fair, Respect the other person, act

Interested, Easy manner, Negotiate and be Direct.


MINDFULNESSLiving your life with awareness

Handout 2

“Mindfulness” means paying attention to what is going on in a particular way:

On purpose: I choose to pay attention

In the moment: I am paying attention to right now

Non judging: I am not thinking about it as “good” or “bad”

Why is it important?

Mindfulness helps us be wise

How?

By balancingEmotions Facts


EMOTION REGULATION

Handout 7

Surfing Your Emotion

1. Notice that you have a strong emotion.2. Notice that you have an action urge.3. Remember, you don’t have to do what your feeling wants you to do.

You are not your feeling.

4. Let go of all thoughts. Do not make this urge bigger. Do not try to push it away.

5. Bring your mind to the way you feel. Find this feeling in your body. Attend to the sensations (e.g., burning, tightening). 6. Notice the feeling coming and going like a wave.7. Notice the feeling getting weaker and weaker.8. Notice your urge going away.

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Action Urge Opposite Action

Run away, hide, avoid

Face what you fear

Fight, attack, be mean, call names

Avoid or be gentle, nice, kind, understanding

Shut down, hang your head low, crawl in bed

Get active, exercise, talk tofamily, play with friends

Hide, avoid Be open about what happened. Apologize and make repairs if you were wrong

emotion actionRemember You can change your emotion byACTING OPPOSITE

tohow you feel

EMOTION REGULATIONHandout 5

Bringing Down Emotion with Opposite Action

Sadness

Shame/Guilt

Anger

EmotionFear


“Three-Headed Dragon” game of chain and solution analyses


Event: Boy called menames

Thought: He hates me

Feeling:Anger

After Effect:Detention

Urge:Kick him

Action: Kicked

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Skills Wheels



DBT-C: PARENT TRAINING COMPONENT

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Parent training component: OverviewCaregivers receive didactics on emotions, training in DBT skills, and behavior modification and validation techniques

• Eight topics are presented:1. Creating a change-ready environment

Hierarchy of child's negative behaviors to be targeted in therapy, and realistic expectations for change)

2. Creating a validating environment

3. Introduction to behavior modification techniques

4. Reinforcement

5. Punishment

6. A(attend)-V(validate)C(coach skills)R(reinforce) model of responding

7. Introduction to Dialectics

8. Dialectical Dilemmas


Emotional Vulnerability

Inability to Modulate Emotions

Main Target: Emotion Dysregulation


Biosocial Theory

Biological Dysfunction in the Emotion Regulation System

Invalidating Environment

Pervasive Emotion Dysregulation

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Biosocial Theory

BiologicalVulnerability Easily activated,

aroused High intensity of

experience Slow return to

baseline

Invalidating Environment

Label emotional expressions unjustified, or inaccurate

Simplify ease of solutions

Periodically reinforces extreme expression

Chronic Emotional Dysregulation Inability to understand, label, accept, or

modulate one’s emotional experience to match goals of the present context


Consequences of Invalidating Responses

• Environment does not teach individual to:–Label private experiences in a manner

normative in larger social community.

–Effectively regulate emotions.

–Trust experiences as valid responses to events.

• Instead, environment teaches individual to:–Actively self-invalidate and search social environment

for cues about how to respond.


Consequences of Intermittent Reinforcement of Escalated Emotional Displays

• Environment does not teach individual to:–Accurately express emotions.

–Communicate pain effectively.

• Instead, environment teaches individual to:–Oscillate between emotional inhibition and extreme

emotional styles.

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Consequences of Oversimplifying

• Environment does not teach individual to:–Tolerate distress.

–Solve difficult problems in living.

–Use shaping and other behavioral strategies to effectively self-regulate own behavior.

• Instead, environment teaches individual to:–Respond with high negative arousal to failure.

–Form unrealistic goals and expectations.

–Hold perfectionistic standards.

A-VCR Model of RespondingHandout 12

A (attend/assess) – V (validate) C (coach skills use) R (reinforce)

Attend/Assess

• Attend to emotions over cognitions, behaviors, situation and context

e.g., “You seem upset”

• Attend to your own emotions if needed

• Assess the situation (context, child’s emotions, thoughts, urges)

e.g., “What happened to make you so angry?”

Validate (one or more of the following)

• Find the “kernel of truth” in what your child is feeling/saying/doing

e.g., “I know you do not want to do your homework. It is not very exciting.”

• Indicate that other people would share the child’s feeling in the same situation

e.g., “Everyone would fell angry about being called names.”

• Validate difficulty of the situation and using adaptive coping skills

e.g., “It’s not easy when your emotion mind is screaming at you and it is hard to think straight.”

Coach skills use (using all four elements maximizes effectiveness)

• Remind the child of her/her goals

e.g., “Remember, you wanted to be the boss of yourself”

• Help the child select a skill to use

• Prompt the use of skill and remember to be specific, calm, close and state the request

Reinforce (using all three types maximizes effectiveness)

• Verbal praise

• Non-verbal praise

• Reinforcing consequences (e.g., points, privileges, rewards)

Introduction to DialecticsHandout 22

How do Dialectics apply to parenting?1. In order to change difficult thoughts, feelings and circumstances you need to accept things as they are in the moment.2. Rigid rules do not help and may hurt your ability to parent.3. Statements that start with "You should always...," "You should never...," "This is only acceptable when..." are examples of "either-or" thinking.4. Rigidity and consistency are not the same. Rigidity is sticking to the same thing no matter what. Consistency is reacting to our child's behavior in a similar manner across situations and caregivers, while being flexible and taking into considerations the demands of the situation.5. Consider the child's point of view and other possible opinions, options and solutions. A decision that takes into account multiple views of a situation is more effective.6. Children are trying the best they can AND need to try harder and do better. A child behaves in a particular way because this is the way s/he learned to deal with past situations. Accept things the way they are AND help your child learn other ways of responding. 7. Change is constant. Realizing that nothing is ever the same, helps parent get unstuck from the situation and move on.8. What parents do and say has an impact on what their children do and say. On the other hand, children’s behavior influences their parents as well. 9. “Do what I say and not what I do" does not work. Actions speak louder than words. Children will follow what is modeled over what is said.

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Neglectful

Pathologizing Normative

Behaviors

Overindulgent

Dialectical Dilemmas

RestrictivePermissive

OverprotectiveDepriving

Normalizing Pathological

Behaviors


CURRENT RESEARCH ON DBT-C


Clinical site:Weill Cornell Medical Collegeand New York Presbyterian Hospital, White Plains, NY

Adapting DBT-C for pre-adolescent children with DMDD: Randomized Clinical Trial in outpatient care

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Disruptive Mood Dysregulation Disorder

A. Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.

1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages or physical aggression towards people or property.

2. The temper outbursts are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, three or more times per week.

C. Mood between temper outbursts:

1. Nearly every day, most of the day,

2. the mood between temper outbursts is

3. persistently irritable or angry.

4. The irritable or angry mood is observable by others (e.g., parents, teachers, peers).


• Pilot RCT (22 cases in DBT-C and 22 cases in TAU) to examine feasibility and preliminary efficacy.

• Primary Aims: drop out rates, number of sessions attended, treatment satisfaction

• Secondary Aim: Responder rate on the Clinical Global Impression Scale

DBT for children with DMDD


Interventions• DBT-C

32 once per week 90 min sessions :- 30 min. individual therapy with a child

- 20 min. individual counseling with a caregiver

- 40 min. skills training with child and caregiver

• Treatment-As-Usual32 weeks (up to 2 sessions per week):

- Supportive individual psychotherapy with a child (52.1%)

- CBT (46.4%)

- Parent Training (42.9%)

- Adjunctive family interventions. (30.7%)

- Psychodynamic (21.4%)

- Interpersonal (20.2%)

- Motivational Enhancement (13.1%)

- Sessions duration as deemed appropriate by clinician

(M=46.9, range 25-85 min)

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Demographics

Number enrolled 44

Age (mean, SD) 9.3 (1.7), range 7-12

Male gender, n (%) 25 (56.8)

Hispanic, n (%) 7 (15.9)

Race, n (%)

Caucasian 34 (77.3)

African American 5 (11.4)

Asian 1 (2.3)

Other 4 (9.0)


Sample characteristics

ADHD, n (%) 18 (40.9)

Anxiety Disorders, n (%) 12 (27.3)

Enuresis/Encopresis, n (%) 5 (11.4)

PTSD, n (%) 1 (2.3)

Two dxs 25 (56.8)

Suicidality/NSSI, n (%) 23 (52.3)

Sensory processing problems, n (%) 33 (76.7)

Previous psychiatric hospitalization, n (%) 5 (11.4)

Previous outpatient therapy, n (%) 37 (84.1)

Special services at school, n (%) 21 (47.7)


Psychiatric medications

Stimulants, n (%) 5 (11.4)

Antipsychotic, n (%) 5 (11.4)

Antidepressants, n (%) 5 (11.4)

Mood Stabilizers, n (%) 1 (2.3)

Anxiolytic, n (%) 1 (2.3)

Other, n (%) 2 (4.5)

No psychiatric meds, n (%) 32 (72.7)

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Variable Mean p

DBT-C TAU

Drop Out Rate (dropped out before week 26)

0 8 (36.4%) .000

Number of sessions attended in 32 weeks 28.4 (88.6%)

15.6 (48.6%)

.000

Child Treatment Satisfaction (range 7-28) 22.77 18.39 .02

Parent Treatment Satisfaction (range 7-28) 26.27 20.50 .000

Therapist Treatment Satisfaction (range 15-60)

44.81 43.71 ns

Number of children on psychiatric medications

4 (18.2%) 12 (54.5%)

.01

Primary Outcomes: Feasibility and Acceptability


• Clinical Global Impression Scale was administered by blind independent raters

• CGI – Severity rates severity of child’s mood and outbursts in the past week and takes into account number, duration, and intensity of episodes; number of settings (e.g., home, school, peers, pubic places); level of disruption per setting; level of accommodation; and changes in the environment that may have contributed to increase/decrease in severity

• CGI-Improvement compares the current level of severity to the baseline

Secondary outcomes: CGI


Secondary Outcomes: CGI - Improvement

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Secondary Outcomes: CGI – Mood and Outbursts Severity

Note: 10.9% of missing data. Intend-to-treat analyses with carry over were used to estimate results.


Secondary Outcomes: CGI – Total Severity


• Results of this trial indicated that DBT-C was acceptable for pre-adolescent children (7- 12 years of age). As compared to TAU, children and parents in DBT-C condition indicated significantly higher treatment satisfaction.

• Drop out rate was significantly higher in TAU group as compared to DBT-C.

• Treatment attendance was significantly higher for DBT-C as compared to TAU.

• DBT-C was significantly more effective than TAU in decreasing DMDD symptoms, as measured by the CGI Severity and Improvement scales. The significant difference between groups was noted for both mood symptoms and behavior outbursts.

• DBT-C was more effective than TAU in reducing symptoms of DMDD despite a 3-fold difference in the use of psychiatric medications between conditions.

• Observed improvements were clinically significant.

Summary: DBT-C for children with DMDD

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1. Unblinding of independent ratersUnblinding occurred for 19.8% of observations. Re-rating of the unblindeddata to assess reliability indicated that the pattern of results did not significantly change (agreement on only 1 rating for the “CGI Response Rate” was not reached).

2. Inclusion of patients receiving psychiatric mediations Given the high severity of population (physical aggression, suicidality and NSSI), requiring termination of psychoactive medications prior to study inclusion would not be clinically advisable or feasible.

3. Differences in treatment conditionsa) DBT-C was a manualized intervention, while TAU did not adhere to a specific manual or treatment approach; b) DBT-C sessions were 90 min. long, while TAU sessions were 45 min long on average (range 25-85 min); c) participants randomized to TAU were charged for treatment through insurance, while participants in DBT-C condition were provided with therapy free of charge; and d) participants assigned to TAU conditions had to come in for an additional intake procedure that included meeting with a psychiatrist and a financial department, which delayed treatment initiation.

.

Limitations


DBT-C for pre-adolescent children in residential care: Randomized Clinical Trial

Clinical site: Green Chimneys ResidentialTreatment Center


• RCT (27 cases in DBT-C and 20 cases in Enhanced TAU) to examine feasibility and preliminary efficacy.

• Primary Aims: number of sessions attended, treatment satisfaction

• Secondary Aim: Child Behavior Checklist – staff report

DBT for children in residential care

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Interventions: DBT-C• DBT for children

- Individual:34 weeksonce per week 45 min individual sessions

- Skills training twice per week (didactics and home-work review)group sessions60 min.

- Caregiver trainingTwice per month (in group or individual in person or via teleconferencing)90-min sessions

- Milieu therapy (modeling the use of skills, prompting the use of skills in everyday life and reinforcement of adaptive coping)

- Token reinforcement program


Interventions: Enhanced TAU

• Enhanced Treatment-As-Usual

- 34 weeks of individual therapy sessions (CBT, psychoeducation, crisis management, and non-directive supportive therapy)

- Twice per week group therapy (CBT, psychoeducation, process therapy and social skills training).

- Twice per month caregiver training in parenting skills.

- Token reinforcement program.

• Clinical site

Green Chimneys Residential Treatment Center that serves 85 children annually, from 6-13 years of age with severe emotional and behavioral difficulties


Demographics

Number enrolled 47

Age (mean, SD) 10.3 (1.5), range 7-12

Male gender, n (%) 100%

Hispanic, n (%) 8 (17.0)

Race, n (%)

Caucasian 26 (55.3)

African American 16 (34.0)

Multiracial 2 (4.3)

Other 3 (6.4)

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Sample characteristics

ADHD, n (%) 36 (76.6)

Disruptive Behavior Disorders, n (%) 35 (74.5)

Mood Disorders, n (%) 23 (48.9)

Anxiety Disorders, n (%) 17(36.2)

Enuresis/Encopresis, n (%) 6 (12.8)

PTSD, n (%) 6 (12.8)

Other, n (%) 16 (34.0)

Co-morbidity, n (%)

Two dxs 16 (34.0)

Three or more dxs 30 (63.8)


Sample characteristics (cont.)

Full scale IQ, mean (SD) 88.9 (14.7) range 70-127

Suicidal ideations 14 (29.8)

Suicidal behaviors 15 (32.0)

Previous psychiatric hospitalization, n (%) 43 (91.5)

Previous outpatient therapy, n (%) 37 (78.7)

Medications:

Antipsychotic, n (%) 34 (72.3)

Stimulants, n (%) 22 (46.8)

Lithium, n (%) 13 (27.7)

Antidepressants, n (%) 12 (25.5)

Sedatives, n (%) 7 (14.9)

No psychiatric meds, n (%) 3 (6.4)


Variable Mean pDBT TAU

Individual Attended 26 25.4 ns

Group Attended 38.1 38.1 ns

Parent Attended 5.2 3.6 ns

Treatment Compliance Total Child 62 61.5 ns

Treatment Compliance Total Parent 48 56.3 ns

Therapy Satisfaction Total Therapist 48 45.7 ns

Therapy Satisfaction Total Parent 21.3 21.8 ns

Therapy Satisfaction Total Child 21.8 21.9 ns

Primary Outcomes: Feasibility and Acceptability

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• Results of this trial indicate that DBT-C was acceptable for pre-adolescent children (7- 12 years of age), including a population with a mean IQ (M=88.9) that is one SD lower than the average.

• Further, it is feasible to implement DBT-C in residential care settings. Therapists were able to demonstrate adherence to the model. Staff training and supervision was an integral part of the treatment.

• DBT-C was significantly more effective than TAU in decreasing a broad spectrum of psychiatric symptoms, as measured by CBCL staff report.

• Results were clinically significant.

• Lack of a significant difference for CBCL teacher and parent reports between groups on most scales highlights the importance of involving caregivers in treatment to help generalize and sustain therapeutic gains.

Summary: DBT-C in residential care


1. Use of parental report for CBCL staff report baseline data Staff report could only be collected after the intervention started. The pattern of results did not change when parent data were included.

2. CBCL reports were collected every 6 weeks instead of 6 months, which may have affected measure’s sensitivity to change.

3. Inclusion of patients receiving psychiatric mediations Given the high severity of population (physical aggression, suicidality and NSSI), requiring termination of psychoactive medications prior to study inclusion would not be clinically advisable or feasible.

4. Differences in treatment conditionsDBT-C was a manualized intervention, while TAU did not adhere to a specific manual or treatment approach.

Limitations


• The results of both RCTs indicate that DBT was acceptable and feasible to use with pre-adolescent children (7 to 12 years of age), including a population with a borderline intellectual functioning.

• DBT was significantly more effective than TAU in decreasing a broad spectrum of psychiatric symptoms.

• Observed improvements were clinically significant on the main measures of outcome.

Summary

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