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