异常与行为心理学

Dialectical behavior therapy: A new frontier in treatment of pre-adolescent children with severe emotional and behavioral dysregulation

Abstract

Francheska Perepletchikova

Background & Aim: Chronic irritability and difficulty with self-control may negatively affect child’s emotional, social and cognitive development and are predictive of personality disorders, dysphoric mood, substance and alcohol abuse, suicidality and non-suicidal self-injury in adolescence and adulthood. Dialectical Behavior Therapy for pre-adolescent Children (DBT-C) aims to facilitate adaptive responding by teaching coping skills and encouraging caregivers to create a validating and changeready environment. Method: Two RCTs were conducted to examine feasibility and initial efficacy of DBT-C, they are: (1) In the NIMH funded RCT of DBT-C for disruptive mood dysregulation disorder, 43 children (7-12 years) were randomly assigned to DBT-C or TAU. Children were provided with 32 individual sessions that included child counseling, parent sessions and skills training. (2) In the private foundation funded RCT of DBT-C for children in residential care, 47 children (7-12 years) were randomly assigned to DBT-C or TAU. Children were provided with 34 individual sessions, 48 group skills trainings and 12 parent trainings. Results: Subjects in DBT-C attended 40.4% more sessions than subjects in TAU. No subjects dropped out of DBT-C, while 36.4% dropped from TAU. Further, 90.4% of children in DBT-C responded to treatment compared to 45.5% in TAU, on the clinical global impression scale. All changes were clinically significant and sustained at 3-months follow-up. In the residential care trial significant differences were observed on the main measure of outcome; Child Behavior Checklist (CBCL) staff report. Children in the DBT-C condition as compared to TAU had significantly greater reduction in symptoms on both internalizing and externalizing subscales. All changes were clinically significant. Results were maintained at 3- and 6-month follow-up. Conclusions: Results of both trials supported the feasibility and initial efficacy of DBT adapted for pre-adolescent children with severe emotional and behavioral dysregulation in multiple settings. Background: Dialectical Behaviour Therapy (DBT) has been used to treat adults and adolescents with suicidal and non�?�suicidal self�?�injury. This article describes initial progress in modifying DBT for affected pre�?�adolescent children. Method: Eleven children from regular education classes participated in a 6�?�week pilot DBT skills training program for children. Self�?�report measures of children’s emotional and behavioural difficulties, social skills and coping strategies were administered at pre�?� and post�?�intervention, and indicated that the children had mild to moderate symptoms of depression, anxiety and suicidal ideation at baseline. Results: Subjects were able to understand and utilise DBT skills for children and believed that the skills were important and engaging. Parents also regarded skills as important, child friendly, comprehensible and beneficial. At post�?�treatment, children reported a significant increase in adaptive coping skills and significant decreases in depressive symptoms, suicidal ideation and problematic internalising behaviours. Conclusions: These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted. Progress on adapting child individual DBT and developing a caregiver training component in behavioural modification and validation techniques is discussed. Dialectical behavior therapy (DBT) is an empirically supported treatment for borderline personality disorder (BPD) in adults, however fewer studies have examined outcomes in adolescents. This study tested the effectiveness of an intensive 1-month, residential DBT treatment for adolescent girls meeting criteria for BPD. Additionally, given well-established associations between BPD symptoms and childhood abuse, the impact of abuse on treatment outcomes was assessed. Participants were female youth (n = 53) aged 13–20 years (M = 17.00, SD = 1.89) completing a 1-month residential DBT program. At pre-treatment, participants were administered a diagnostic interview and self-report measures assessing BPD, depression, and anxiety symptom severity. Following one month of treatment, participants were re-administered the self-report instruments. Results showed significant pre- to post-

treatment reductions in both BPD and depression symptom severity with large effects. However, there was no significant change in general anxious distress or anxious arousal over time. The experience of childhood abuse (sexual, physical, or both) was tested as moderator of treatment effectiveness. Although experiencing multiple types of abuse was related to symptom severity, abuse did not moderate the effects of treatment. Collectively, results indicate that a 1-month residential DBT treatment with adolescents may result in reductions in BPD and depression severity but is less effective for anxiety. Moreover, while youth reporting abuse benefitted from treatment, they were less likely to achieve a clinically significant reduction in symptoms. Borderline personality disorder (BPD) is characterized by repetitive suicidal and non-suicidal self-injurious behaviors, extreme emotion and behavioral dysregulation, and disruptions in interpersonal relationships . Despite prior controversy around diagnosing personality disorders in youth, it has become increasingly evident that personality disorders can be reliably diagnosed in adolescents, showing good concurrent and predictive validity and similar stability as seen in adults. Among adolescents, BPD is estimated to affect approximately 3% of the general population with higher rates seen in psychiatric populations (i.e., 11% of outpatients and 50% of inpatients. Further, numerous studies have found associations between BPD symptoms in adolescence and serious psychosocial consequences later in adulthood . Accurately diagnosing and treating BPD earlier in the disease course may, therefore, help to prevent maladaptive behavior patterns from becoming ingrained and intractable to treatment later in life.In addition, youth with BPD have high rates of comorbid psychopathology, reporting an average of three additional diagnoses Mood and anxiety disorders are the most common comorbidities. However, substance use disorders and post-traumatic stress disorder (PTSD) are also common and predict worse outcomes and reduced likelihood of remission Given the clinical and public health significance of BPD, identifying effective treatments for adolescents with BPD that target both core features of the disorder and the associated sequelae of common co-occurring disorders is essential.There is strong support for the effective use of dialectical behavior therapy (DBT) in treating BPD in adult samples, including numerous randomized control trials (for review see. Subsequently, DBT was adapted for use with adolescents with promising initial results. Much of the research on DBT’s effectiveness with adolescents, however, has examined outpatient treatment whereas youth with multiple comorbid problems, serious emotion dysregulation, and impulsive

behaviors, likely to benefit from DBT, are frequently referred to residential treatment settings. To our knowledge, only four studies have examined the effectiveness of DBT for adolescents in residential settings. Despite this limited evidence, results are promising with reductions in overall symptom severity depression symptom severity, and number of inpatient days. However, the treatment duration assessed in these studies was quite long, ranging from four to 29 months and cannot speak to the effectiveness of residential DBT delivered in shorter time frames. The current study seeks to assess the effectiveness of a residential DBT program delivered in a single month (i.e., 28 days).Additionally, the pervasiveness of childhood abuse among individuals with BPD is well documented, with 27–81% of adults with BPD reporting some type of childhood abuse. The severity of childhood abuse, including the duration and nature of abuse, has been found to positively relate to both the severity of BPD symptoms and level of psychosocial impairment. Additionally, a history of physical and/or sexual abuse predicted poor outcomes for youth in residential treatment. Given the high prevalence of abuse among adolescents with BPD, it is critical to consider how experiences of abuse may moderate treatment effectiveness.