Lecture on DBT for Children

okay so before you proceed I just want to disclose that my research has been funded by private foundations and an mah one thing that&#39;s not there that I have to disclose that I&#39;m a contracted trainer with behavioral tak and SF mentioned I started this work at Yale and staff was the one who started training me in DBT you&#39;re my sensei and it has been amazing amazing I remember when Seth just started to train me and I was trying to get to adherence and DBT and that was you know taping all of my sessions and he was looking for them and the very first actually the second tape that he was able to see initially we had problems with sound and I&#39;m sitting down here he&#39;s telling me you know what I have one good news and what bad news the good news is we have sound the bad news it&#39;s not DBT and you know what now I agree with him because now I understand what is involved in becoming a DBT therapist and I of course want to thank John Hoffman Lawrence Cahill Heather Douglas Paula Murray who are all here and say thank you so much for all of your support without your help and enthusiasm for what I do it will not be possible so of course I also want to thank people at my new home at well Cornell where I am under the wing of John walk-up Donald Nathanson my fabulous fabulous fabulous DBT therapist and I walk up who is my therapist as well she&#39;s doing treatment as usual on the other side they actually here in the audience they told me if I ask them to wave they&#39;re going to be mad at me so please wave all right yeah no I don&#39;t see her okay so I also want to say thank you so much for the people at Green chimneys that&#39;s one of the studies that I&#39;m doing with children in residential care and they really did not know what they were getting themselves in when they invited me and say hey let&#39;s build it up and it was supposed to be a one-year study we are year five now and I continue to tell them that we need to change change change and they continue to tell me yes we do some things are happening some things are not but this is reality okay I&#39;m not attached to my slides there are many more of them more than I can actually cover in the talk most of them are for your information and and of course you can ask me whatever questions you&#39;d like on anything that I&#39;m missing and I&#39;ll be available throughout the conference and you can also email me my email be at the end of my slides so we&#39;ll talk a little bit about what DBT is all about I&#39;ll tell you how I was able to adapt it to children and some of the very preliminary look at what the children look like unfortunately I don&#39;t have the results yet I was working feverishly one of my studies active treatment is done but we were not able to get the data and fortunately in today if this conference was tomorrow then yes but not today I know a Matisse okay so DBT overview I can&#39;t go too much detail with DBT is all about how many of you know what DBT is okay fantastic all right okay so for those who don&#39;t DBT is behavioral DBT is cognitive but this is so much more above and beyond that and the main thing that I want you to remember is DBT is about balance it&#39;s about balance between acceptance and change and everything that we do in DBT in so in terms of skills training or in terms of the strategies and procedures that therapists are involving and using it&#39;s all either falling on the acceptance or the change continuing why acceptance is so important because if you don&#39;t accept that they have a problem there&#39;s no change one of the examples that I really like on this alcoholic anonymous the very first thing that a person does is what they stand up and they say what I&#39;m John Doe and I am an thank you why is that important person accepted I&#39;m here because I have a problem and therefore change is possible people with substance use alcohol abuse what do they say usually if they don&#39;t haven&#39;t accepted it yet I have no problem kidding me I can quit like this tomorrow on that you know yeah that&#39;s not an issue for me so if there is no acceptance what kind of change is possible what are we doing with that if you&#39;re just talking about acceptance acceptance acceptance alright that&#39;s actually okay if you&#39;re just talking if you&#39;re just accepting if you just there for the client if you&#39;re just giving in validation and understanding Klein is going to continue to come however at some point Klein will still start experiencing high level of arousal and sense out of control and will feel invalidated because yes you understand me but you haven&#39;t helped me to resolve anything it didn&#39;t help me to change if you just focus on the change and tell him you know there are some of the issues we need to resolve them how we&#39;re going to do it again high sense of arousal feeling of out of control no collaboration no learning because what is what&#39;s going on there is that the therapist is assuming that in validating role of saying you have a problem you need to change this is pretty much what they have been hearing since they were very little right parents telling them you have a problem what&#39;s going on you need to change so acceptance is extremely extremely important not only from the therapist clients are learning to accept themselves and accept their issues before they can proceed to changing them what is our main target in DBT is of course emotion regulation and what are the tasks we want to decrease mood dependent behaviors we want to help them reorient the tension and very importantly organize their attention in the service of their goals now what Emery era was talking about in the previous presentation she was talking about this invalidating environment the mothers who are having difficulties raising their children and they may be doing things that is not helping the child to get you know to get where they need to be and actually may prevent them to get to the well-being say that they want them to be what in DBT we have a biosocial theory in which we&#39;re saying you know what what it is it&#39;s a combination between the biological predisposition to experience emotions in a different level the sensitivity to the emotions the vulnerability and it&#39;s in boring and then the child who is that sensitive and vulnerable is born into the environment that cannot help and support that and it may not necessarily be an environment that is actually abusive or neglectful now yes it can also happen but we&#39;re talking about here it&#39;s a mismatch between what the child needs and what the parents can give they can&#39;t match the needs and I don&#39;t see it at the theory for me this is an everyday occurrence what I see with my clients and you know what some of the self disclosure I have to say is that I have two kids I have a 16 year old daughter and I have a nine year old son they&#39;re diametrically opposed different my my daughter is like a duck in the waters everything just rolls down a feather she&#39;s very resilient if you want to call it that my son he&#39;s the sensitive one he is the one who would be like I have a cut I&#39;m gonna die and he actually thinks that he actually feels it it&#39;s not dramatic if he&#39;s like histrionic it&#39;s this is this is the level of fear and emotion that he has and oh boy am I happy that I was ready to actually know what to do it with such a sensitive child because what is going on with children who are born sensitive is that they indeed have very easily activated arousal meaning that little things for us maybe not even noticeable activate them and they react very very strongly somebody didn&#39;t look at me right somebody didn&#39;t say hi I dropped my toy in it cracked whatever it may be and now the child will just go pass it and not notice this chat will have a huge outburst and it will be very hard for that child to calm down and sometimes we may not even understand what&#39;s going on we may think that it comes out from nowhere well you know what something is going on inside that child some thoughts them feeling some memories something and environment make you it boom there is an outburst so these children go from one to hundred pretty much in zero time a lot of the times and it&#39;s very hard for them to stop and then we couple it with what we call in an invalid dating environment and again don&#39;t be treated by the name all that means that again not necessarily abuse and neglect parents don&#39;t know what to do with this kid they feel trapped because these kids don&#39;t come with instructions none of them come but these kids particularly need them and what happens is the parent is saying oh my god what&#39;s wrong with you why can you just stop why are you reacting so much to such a small thing why can&#39;t you be just like your brother come on just stop it just snap out of it and from all of that what happens is chronic emotional dysregulation one of the things that I want to also say that that the environmentally brain is that a lot of the times when child is having the outbursts the environment is not going to respond or respond and not an in the way that&#39;s supportive and then child learns that you know what if I have a severe outburst that involves me saying I&#39;m going to kill myself I&#39;m actually you know what everybody comes running so environment can actually also support extreme extreme expression of the emotion so what we have out of that is an ability to understand and label their emotions because everybody&#39;s saying by angry not supposed to be angry why are you feeling angry no I don&#39;t feel angry well child is like okay I guess I&#39;m not feeling angry so kid is really confused now they can of course modulate the emotional reactions because maybe parents aren&#39;t themselves not sensitive and they have never learned how to deal with them and how they supposed to understand the child and teach the child how to modulate their emotions they&#39;re clueless ybb team there&#39;s huge amount of empirical research right now on its effectiveness in tackling exactly what we need the emotional regulation and it has been you know have such such an incredible empirical support in the literature for adults Alec Muller that it&#39;s with adolescents with high degree of success and they&#39;re all kind of studies supporting what it&#39;s doing to the brain activity so I&#39;m not going to go into that however what I want to say is that if you&#39;re think about a sensitive child who has what&#39;s now in dsm-5 called disruptive mood dysregulation disorder we&#39;ll talk about this a little bit later in my view you know I would not be surprised if research shows over time the children with disruptive mood dysregulation disorder some of them are on a trajectory to have borderline personality disorder later in life just like children with conduct disorder and some of them are in trajectory to develop antisocial personality disorder because a lot of things that we see with children with severe sensitivity and vulnerability is what exhibited by patients with borderline personality disorder you know a lot of kind of either-or thinking suicidality behaviors extreme expressions of emotions it&#39;s all there so what did we do to adapt DBT for children again you have a lot of slides there that I will not cover in detail there for your information and I will be very very happy to answer your questions either today or over the email some of the things that were added to the DBT model we needed to make sure that children can actually understand what emotions are we needed to make sure that parents can understand what the emotions are why they why we need it we needed to understand how they start how to what to do with them and how they&#39;re different from thoughts and behaviors so we added didactic on emotions to the individual part some of the skills have been changed simplified condensed and you&#39;ll see a bit later that we even have different acronyms here&#39;s some of the handouts stop scale this is something that has been developed for DBT for children to help them stop the reactivity in the moment the impulsive behaviors in response to distress actual marsha linehan really liked that scale and now it is also a part of DBT for adults so what that is just to give you an example of how we do it with kids stop is an acronym S stands for stop freeze don&#39;t move a muscle if you indeed can do that 70% 80% of your problem is solved because you&#39;re indeed we&#39;re able to become aware that you&#39;re about to react and if you react it&#39;s not going to make it better may actually make it worse you are willing to actually stop meaning that you&#39;ll be willing to do something different about it then the rest of this is you take a step back you detach them from the situation a little bit you&#39;re breathing in and out to calm down then you&#39;re much more ready to observe what&#39;s going on inside and outside of you you need the information and then once you have this information little bit calmer you did hatched you didn&#39;t react now we can proceed mindfully you can ask your wise mind what to do depending on your goals so how do you do that you train the practice roleplay a lot every day instructing parents you have to do a lot of hypothetical situations in which the child will may be reacting and you want to instruct him to freeze and we give all kind of rewards at the end of it even if it&#39;s hypothetical so the more parents are able to roleplay hypothetical situations the higher the probability because it&#39;s a behavioral rehearsal the child will actually be able to stop and freeze in the moment when they are to become dysregulated it&#39;s very important practice practice practice is born for everybody for children triple importance well I&#39;m not going to go again in depth what we did to adapt as I said we simplified them all four modules are there mindfulness and personal effectiveness and motion regulation distress tolerance everything is there these acronyms a little bit different and more child oriented some of the handouts on the skills opposite action alright the three had a dragon of chain analysis so chin analysis chain and solution analysis and DBT is something that is staple trying to figure out what is it that happen and what to do instead it&#39;s quite a difficult thing to do with adults they don&#39;t like doing it and sometimes it&#39;s so toxic that therapists collude would decline not to do chain analysis so therapists have to be really careful to really understand the reinforcements that are going on the negative the positive they&#39;re so because their behaviors are also being reinforced by the client reactions well anything that we do with kids the easiest way to teach it through games right so this is a game and people are asking me how did you come up with a three-headed dragon I said well was easy for me all dragons and Russia have three heads it&#39;s a Russian dragon how do you use it alright emotion wave everything starts with event emotions don&#39;t come about by themselves something has to trigger them so emotion wave is event then not feeling interpretation of the event because that interpretation can can can make a difference in in terms of how you feel about the event then the feeling the cup brings in all kind of sensations urges to to act such as when you&#39;re angry you want to do what yell fights grad fight right and this is the action urge now you don&#39;t have to do it you&#39;re not your emotion you may actually say to yourself you know what this what emotion is telling me to do however in that situation that&#39;s not going to be effective for me to move to actually do it what tells me to do so then you have action whether or not you&#39;re going with the emotion depending on the situation the action urge and then of course the after effects positive negative consequences more thoughts behaviors are the people saying and doing things and all of that can start all new wave and that&#39;s very important to remember because how long do you think one emotion lasts one one discrete emotion yes five seconds all right two minutes all right so one discrete emotion lasts about 40 seconds when I tell it to cry and they say what are you talking about I&#39;ve been mad for three weeks now then since that happened telling me it&#39;s 40 seconds as a yes it&#39;s 40 seconds because what happened was you had one emotion anger and then you start eliminating you start doing things that anger wants you to do fights scream you know you know send texts that are angry you know whatever it is that you&#39;re doing and then that one discrete emotion turns into what you mean the same emotion here we have a mood all right so you know all of these things are actually what I&#39;m describing giving you a sample of what we talk with children when we&#39;re doing didactics on emotions so we&#39;re using our wave paradigm in terms of how emotions comes up when we do the Dragon game all right for example event a boy called me names thought you know what he hates me and you know what happens people who have such strong emotions they take their thoughts and feelings and they take them underneath and they actually think of them as facts that&#39;s why you know check your facts thing and dbj of course feeling of anger it&#39;s a fact he hates me now what&#39;s the urge to kick him what did actually happen I did kick him and I got into detention and then you say did it go okay you know what I totally understand why you would feel angry somebody calls your name names I would feel angry too we call it thank you validation all right very important staple we need to have validation that&#39;s one of the acceptances strategies geez did you like the outcome the detention did you like to get into detention no all right so what do you want to do with that next time somebody calls your name what are you gonna do do you want to think of something different yeah then what we do we interrupt the urge and the action by our stop skill you have a feeling have an urge freeze don&#39;t move a muscle all right what I&#39;m gonna do here and I am going to maybe go and tell a teacher after I stop them freezed that&#39;s one solution another solute and then the after effect would be you know I would get praised I&#39;ll feel proud of myself you know what I&#39;m the boss of myself that&#39;s one of the goals that we have for these kids to be the boss of themselves and of course they want to be proud and want everybody proud of them now another solution we always need a backup walk away and what will happen is again feeling proud of myself you know situation did not you know at first maybe even cut better all right so this is pretty much the chain analysis in a very simplistic way and you can go higher and higher you know with with all those cards and this is actually a game you know it&#39;s a huge poster you know with its magnet receptive materials so you know the little carts were placed on it you know we&#39;ll write all of this out with the child and and then you know we actually sometimes write it on the sheet of paper so the children can take it back and look at it next time do you they need to figure out what to do okay so there&#39;s some of the things that we came up with in terms of using the skills sometimes children would stop and freeze and then they kind of like okay how do I proceed mindfully what do I do they make I kind of get stuck because there&#39;s still emotional and this is something that we came up with was it&#39;s it&#39;s it&#39;s skills we&#39;ll what you do is it&#39;s this actual skills rules from some of my clients you have a will and you you know the are your favorite skills you put there and you just flip the error and whatever it ends and it lands on you have to do it simple enough and also introduces the game in it in some fun okay so diary card absolutely children I don&#39;t care it&#39;s diary card we need to have it and of course we&#39;re not expecting that the child is going to be able to do this without a parent we actually not expecting the child is going to be able to do any of this without a parent I&#39;ll talk about this more so parents are there to help them what we&#39;re tracking is emotions we&#39;re trading suicidality self-harm we&#39;re tracking ineffective behaviors such as depression destructive behaviors were tracking effective behaviors absolutely such as ignoring walking you or whatever it is and then we&#39;re looking at which skills they were able to use throughout the week Wow parent training component well you know what DBT is not an individual therapy for a child absolutely not it&#39;s a family therapy the more you do it the more I realize that it&#39;s a family therapy because otherwise it&#39;s like doing couples therapy with seeing individually separately you can&#39;t do that you need the diet there sometimes I do child&#39;s up assist a child separately for the individual however a lot of the time especially if the child is is is like seven eight nine I do absolutely you know most of the time have a parent in there because it&#39;s a problem in the relationship that we need to resolve and the parent beings there that&#39;s that&#39;s the child&#39;s world that&#39;s where they&#39;re coming from that&#39;s that&#39;s the environment you know the validating or invalidating environment that can actually support the child or get the child in a position that they&#39;re going to be more and more dysregulated now keep telling my parents you know what there are there&#39;s absolutely no way I&#39;m going to see that child if you don&#39;t commit to doing it with him full force four cardinal rules of parenting in my mind number one they&#39;re very simple and very hard to do number one model the behaviors you want how you expect your child not to scream kick and fight if something comes up you&#39;re upset you scream at your kid or you physically punish them absolutely can&#39;t and then sometimes parents are telling me well yeah but it&#39;s so hard to ignore them because I feel so upset when they do this and that and I say absolutely it&#39;s very very hard are you kidding me I&#39;m a parent I know what it looks like you think I don&#39;t want to throw my kids out of the balcony yeah sometimes they do it&#39;s very very hard and on the other hand listen we&#39;re asking you seven-year-old to learn all of these skills so the key can be in control of his emotions and you&#39;re telling me that you or forty-five-year-old cannot do it because it&#39;s hard please you have to understand whatever behaviors you model that&#39;s the behaviors the child is going to do parents come in a lot of the time with an expectation that child should be polite should be respectful should be following directions right away bla bla bla bla and they&#39;re shocked when I tell them absolutely not child should not do any of that none you reinforce it they do it you don&#39;t they don&#39;t do it simple as that what our shoots shoot same position in reality this is the picture that we draw of how we want things to be and then we impose it on reality in matching and then we continue to pose and impose it imagine that we&#39;re continuing to make us ourselves very very upset and what happens with that is that we turn pain into suffering what is the difference first thing that I want to say is sometimes parents you know coming in and say I can do it you know this this is very hard you know what this is is that we have a delusion and it&#39;s truly a delusion not my words this is marshal in hands words that we cannot tolerate pain yes we can pain is an integral natural part of our lives we need to have it because if you&#39;re sitting at the beach sipping pina colada you&#39;re not learning anything right it&#39;s very very important to relax however there is no challenge that are presented to you that you need to overcome and solve and if you do overcome and solve them you progress to the next level of mastery understanding and learning if you hide away if you run from them if you avoid what happens is you turn that pain into suffering suffering is pain plus not accepting of that pain because of that delusion that we can&#39;t tolerate it parent who is giving in to the child temper outbursts in a store because they can&#39;t accept the pain of child screaming and they and everybody is looking at them and judging them and thinking what a bad parent you know you are and they said have it stop it just stop it you know what that that parent was not able to tolerate that pain in the moment now they turned their pain into suffering because every time child was that kid in the store you bet he&#39;s gonna do it and it&#39;s going to be very hard to extinguish one of the things we teach a lot of the things that we&#39;re teaching it&#39;s very important for them to understand that they need to accept their child as the child is there&#39;s nothing there are no bad people a good people we are all people that&#39;s it parents always ask me how I&#39;m able to tolerate their children in the session because they are bouncing off the walls really well I have several answers to that the first one is that I have my hierarchy of what I want to do you know me having that child sit in the chair quietly and that&#39;s my whole time spent on getting in that chair you know that&#39;s not worth it I want him to learn I want him to listen if he&#39;s bouncing off the wall but he&#39;s answering my questions and I know that he&#39;s processing and understanding that&#39;s it I don&#39;t care number one number two I accept I accept another judge it&#39;s a child you know he&#39;s doing it you know because there is some kind of a function to that behavior very important what is the function of behavior if you can accept child for what they are not judge them because a lot of the times parents are sitting there and judging the child and judging themselves oh my god she&#39;s gonna think I&#39;m a horrible parent oh my gosh she&#39;s gonna think my child is so you know bad behaved and and they get discombobulated with that and they can&#39;t tolerate it and they look at me I&#39;m like so relaxed and he&#39;s like making grounds on my head and throwing things and whatever you know it is what it is but I&#39;m sitting there I&#39;m not just staring at the wall I am figuring out why is the child doing this and how can I help this child do differently if you have that bowl as opposed to continuing to judge and like be tense about this two different ways of handling the situation okay so function of the behavior is extremely important very good example one of my mother&#39;s five kids single parent one of her daughters is very aggressive to the siblings she is kicking screaming taking their toys whatever it is what the mother is doing whenever she&#39;s aggressive for this you know it for the safety of the other kids she grabs that child drags her to different room restrains her and starts telling her to calm down well was the function of the behavior what do you think exactly can you imagine five kids this mom doesn&#39;t have time for all of them you know to the degree that they may want so this kids you know was actually using that behavior to get that hug to get that mom to themselves so hypothesis you know what maybe that&#39;s the function of the behavior let&#39;s test it you&#39;re going to get the child the child is going to get exactly the same thing by you by yourself in the room hugging talking whatever it is for poor social behaviors such as sharing being nice to their to the siblings you know talking nice that whatever it is you know what solved I could have thrown all kind of skills to that child walk away when you work of you know provoked by your sibling you know when they take your toy breathe whatever it is I could have reinforced every time she would go away and it&#39;s not gonna be consistent it would not stay it would not be maintained or be very useful maybe sometimes because the function is not solved you figure out the function figure out how to solve it in a different way you&#39;re done a lot of what we&#39;re doing we&#39;re talking about side-effects of punishments we&#39;re talking about the dialectic of parenting I&#39;m not going to go into any of that it got a taste of this here and there what I want to make sure that that you understand that what we do a lot of it is not necessarily teaching the what to do with the behavior the change a lot of our work is on helping the parent accept accept the child and accept themselves and when we talk about the function of the behavior so that the parents will instead of getting discombobulated about their child being bad they wouldn t be able to actually figure out what the function of the behavior is and how does how to help that kid get that function and just just the other day oh my god it&#39;s a great story just the other day I have this nine-year-old who is sitting there and he thinks that his mother hates him and you know what his mom doesn&#39;t hate him but that&#39;s exactly what she exhibits with the way she talks to him with the way she screams at him with the way she&#39;s comparing him to siblings and so forth so on and this nine-year-old is sitting there and you know I&#39;m talking to him saying you know what he must be feeling very sad thinking that your mom hates me and this nine-year-old looks at me and he&#39;s saying I&#39;m not sad I am ashamed I&#39;m you know who&#39;s ashamed of himself on that level he can actually understand and verbalize it ashamed that he&#39;s not good enough because he&#39;s continually getting that message being screamed at it being told what I&#39;m doing is wrong what I&#39;m feeling is wrong what I&#39;m thinking is wrong everybody else around me or better I cannot control myself what are they supposed to think about themselves absolutely that deep deep shame and you know what comes from deep shame one of the functions of the behavior that we&#39;re seeing Chuck was miserable wouldn&#39;t want to make the parent miserable one of the functions when you understand that you first need to start repairing the relationship you can&#39;t teach skills and blah blah blah no no you have to step back and say okay you need to pair the relationship in a way that&#39;s going to actually be helpful in and support all of the what we&#39;re going to be doing in top of it we want the child to actually want to be reinforced by the parent when the child to be around the parent on the child to look up to the parent and want to please them as opposed to make them miserable if we have that excellent we can really capitalize on that that&#39;s why I continue to tell parents the cardinal rules of parenting model all the behaviors you want number one number two if you don&#39;t like the behavior how whatever it is name-calling swearing whatever it is as soon as it&#39;s not safe it&#39;s not as soon as it does not have any problems with safety to the child or somebody else of property ignore ignore ignore very hard to do well you know what you have all those skills you know use your skills you can or you like the behavior reinforce it parents don&#39;t do it you know a lot of the times their attention is actually dragged to the negative because this is very very understandable our emotion mind somebody is screaming you we turn to that and we actually want to do something about it you know how many times do you have you seen children sitting on the floor playing together nicely parent coming in and saying oh my god guys I&#39;m so happiness playing so nicely together great job I&#39;m gonna get two cookies and milk and whatever you know it&#39;s a quiet okay I&#39;m going to go so as soon as kids stop squabbling what happens what&#39;s going on here why did you do that what did you say there&#39;s so much attention paid what do you want one of the functions of the behavior kids got reinforced by attention by doing for doing what they&#39;re doing they&#39;re not manipulative not pushing buttons they&#39;d be heated that reinforced because that&#39;s that&#39;s how they know how to get what they want they have a temper tantrum parent can take it because apparently we cannot tolerate pain right and then they give them whatever the chat once boom child learned all right that&#39;s what I need to do next time so what does the parent want okay so we have modeled the behavior you want reinforce what you like every little thing because the reinforcement doesn&#39;t happen because of the shoots why should it be reinforcing my child for being polite he should be that or being respectful he should be that or for following directions he should do that right no he should do nothing and the fourth one is play with the kids have fun with them if you have a child who actually enjoys your company how much more reinforcing your place is going to be how much actually he&#39;ll be looking up to and want to spend time with you and would want to make you feel proud and happy instead of miserable so he think I want to come home after a whole day of clients bouncing off the wall and playing nerf gun with my nine year old running around the house shooting no or watch anime with my daughter on YouTube oh my god scare me it&#39;s what I do because that&#39;s what they like and I want to share in that and they look and they&#39;re waiting for me to come home because I&#39;m the one who&#39;s actually taking their interests seriously and you know what I have very very very minimal problems with my kids my daughter only had three temper outbursts in her entire life she was three she knew how to execute them perfectly I am NOT a germaphobe however I actually don&#39;t like when my three-year-old is on the floor in a shopping mall doing this and I have to stand not look the three monkeys you can look can hear can talk perfect image of ignoring stand there and think oh my god what kind of bubonic plague she&#39;s gonna bring and I have to take her to the emergency room right now after this so but I was able to tolerate that and then BOOM after three times trying she learned an air mom in budging so that&#39;s what we&#39;re hopefully going to instill in our parents but to do any of that they need to first accept and let go and see their children for what they are human beings with behaviors that I learned and the learning is there and we need to help them to learn something different to get to their goals alright I&#39;m not going to go through the slides how much more time do I have to go oh my gosh alright current research on DBT this is my wonderful outpatient research team Donald Nathanson wave ha Amy Caitlyn and me over there oh did the dragon remember we talked about the dragon alright so this research is with children with disruptive mood dysregulation disorder very neat clear-cut study only kids with dmdd what&#39;s team did he multiple at least three behavioral outbursts that are not in proportion to the situation he didn&#39;t look at me right I have a temper outburst for an hour or my client yesterday she got a portion of ice cream that was smaller that she wanted she had an outburst I think for five or six hours with kicking the car taking the mom running into the streets you know the whole gamut of things and in between of the of the outbursts the child exhibits irritable angry mood so I just want to make sure that we understand these are not kinda kids there&#39;s a completely different breed of kids they&#39;re sensitive kids they are not the one who are aggressive and they&#39;re and they are proactive they&#39;re not the predatory type they look on the disorder they are reactive type they are reactive time because emotions feel different to them we may not be able to appreciate what emotions feel to them because if what we experience emotions from one maybe to five they go straight to 10 it&#39;s so overwhelming it&#39;s almost toxic they can&#39;t contain it it spills out ok so this study 44 kids oh my god as Donald how we got there it&#39;s all him all him or him thank you so much and 22 in each condition its DBT for children versus treatment as usual whatever is usually right now delivered at Cornell and my studies we&#39;re just starting to do DBT with kids so the studies that I&#39;m doing are going to stage one visibility and maybe some preliminary efficacy but what we want to see is can we do it with pre-adolescent kids can they understand it can they use it again their parents do it can we do it in the format that we&#39;re doing it because it&#39;s a little bit different from the usual the format is so this is this is the inclusion criteria and the format is in a way that we need to do sessions with the child and the parent in it so we can have child coming in by themselves we absolutely need to have a parent component in it because the parent needs to learn then we want everything that I said about you know their their own reactions to the kid and how to modify they also need to learn what the skills are so that they can model them themselves they can prompt the use of skills from the child they can coach the child and the use of skills so they have to be there 100% and the way we did it is that everything that we&#39;re teaching didactically to the child will be that skills be the didactic of emotions parent are absolutely have to be there also parents receiving their separate training in behavior modification techniques and validation techniques and I&#39;d ended at techsan what is the dialectics on parenting and they&#39;re receiving skills training together so session in the outpatient looks like they&#39;re well again you know it&#39;s a function of a form and DBT nothing is set in stone 30 minutes with the child 20 minutes with the parent 40 minutes with skills and then you mix and match whatever you need to do okay the other challenge was skills training the skills training in DBT for adults and adolescents is groups you know what put in a group seven-year-old with a thirteen-year-old what are you gonna get and parents on top of it nobody&#39;s getting anything right you really need to be very careful because the developmental levels the cognitive levels are so different you really have to understand your population and really have to do it on the individual basis that&#39;s why the skills training is in there you know within the individual therapy well this child is not just behaving that way at home schools are also a big part of this remember dmdd is at least two settings so we&#39;ll always have something else going on outside the house and you know we always have to figure out how to approach the schools and do programs in the school settings and that&#39;s actually quite challenging on some levels and on some levels it&#39;s very rewarding because you can see how the teachers are starting to understand the concept that we&#39;re teaching and some of the teachers are telling me you know what I use this on all the kids down this is fantastic thank you so much for teaching me this okay so DBT for kids is the 26 sessions but again sessions with its topics you can deliver them so far in 32 week format whichever way you want it treatments usual is pretty much exactly the same twenty six sessions but they can go all the way to 32 weeks and then we have three months follow up with some booster sessions in between one two booster sessions per months and this is clinical side this is well Carnell and your presbyterian okay so what our look kids look like we have pretty good split between merino males and females most of them Caucasian hiya CS also parents are reporting a psychopathology themselves high education no high level of education in the family and third of them actually got parenting training which I don&#39;t know what kind of parents were training it was because most of them coming in and telling me yeah I&#39;m doing point chart but it ain&#39;t working because there ain&#39;t doing it right this is what they are look like in terms of diagnosis we have a lot of ADHD actually lower than I would explode then I would be expecting but pretty much their anxiety disorders interesting you see we in our samples you know as opposed to what literature shows we did not have anybody with diagnosed depressive disorder outside of the dmdd and which is absolutely understandable none of them are also diagnosed with conduct disorder which actually can as per the diagnostic manual II can have a bit scammer ability but in my mind there are like two things on the opposite extremes you know reactive and proactive aggression and you know a lot of them had multiple diagnoses actually half of them now when I talked to you program officers in Grand you know NIH whatever it is they keep asking me so why do you need to do DBT this is so big and this like you know so complicated do the excuse actually need it are you kidding me no and I say seven-year-old more than 50% suicide I didn&#39;t sell calm seven-year-old eight-year-old nine-year-old you know where they&#39;re going with that trajectory yeah we need this alright well it was interesting when we&#39;re starting assessing those kids this something that we haven&#39;t been starting to do at the very beginning of the study but we added that measure because parents were telling us our child has sensory processing issues with sounds taste touch either than with their siblings and when we actually incorporated into it into the assessment we saw that yeah you know t-scores this is the kind of like a 70 and above is severe problem and some problems you know up to 70 so a lot of them are either some problems in sensory processing or definite dysfunction in sensory processing meaning that there&#39;s something in the brain the sensitivity is spread out its physical sensitivity and emotional sensitivity it&#39;s very very interesting I was very excited about that yep they all have definitely serious you know you know issues with functioning on sea gas a lot of them had previous outpatient therapy some had hospitalizations and almost half of them have special services at school like one-on-one people who are following them around or special schools or whatever it is because they&#39;re very hard to maintain them in the community now they are on medication yep and a lot of them are actually on stimulus with Hannibal you know ADHD and here&#39;s the breakdown so some of them actually more than one or two meds okay DBT see for children in residential care so this is my crew in green chimneys residential care fantastic fabulous therapists I love working with them they were so hungry because they were feeling overwhelmed didn&#39;t know what to do with these kids you imagine and they&#39;re really jumped in with both feet and eat it up so there we have 47 cases 27 DBT and 20 in treatment as usual and our inclusion cream this is much messier study remember that one dmdd very clear-cut this is pretty much everybody unless they have mental retardation and well look at that we have very low threshold what we call mental retardation so a lot of them have come of problems unless they have PDD or psychosis or bipolar they&#39;re in so we have a lot of variability there so I I don&#39;t know what that date is going to look like and again our main issue was to figure out can we do it can we build a program like that in residential care for children well will they be coming will they be accepting and then the second question is you know what the benefits are okay so it&#39;s pretty much very similar 26 individuals to 26 skills training session now remember DBT function of a form here we can actually do group trainings and skills because these children are by units by age so we have lots of 7 8 year-olds in one unit and you know so forth so we can actually do it it&#39;s programmatically possible infeasible to do group you know skills training with kids now when I moved into that doing the studying residential care at Green chimneys I moved in very opportune time because at that point they were constructing new dorms and I was actually able to randomize kids TBT dorm to u-dor separate staff separate therapists fantastic because otherwise what are you gonna do put a dot on the child&#39;s head and said you treat that one with the dot this way and without it the other way not possible it&#39;s a very rare opportunity I&#39;m very very grateful to Green Teams to inviting me and actually long need to do this now you know this is a treatment as usual that they&#39;re doing now some of the challenges there is that they&#39;re there for two or more years you know they continue to you know have the same DBT group all over and over again and some of them don&#39;t need it anymore so what do you do well we actually do a levels of groups so newcomers at least you need to have at least two rounds of DBT so it&#39;s full year of DBT and then if they actually did that they either go to pre graduate the Graduate pre-graduate children completed all of that two rounds of DBT skills training however they still continue to struggle to implement it then we&#39;re doing pre graduate when it&#39;s DBT heavy with an application actual application to the dorm in their lives and then the graduate group it&#39;s talking about this church and talking about you know real life TBT in real life what would they need to do how would they need to use those skills outside of the program the other one was reinforcement ah just like with parents punishment something that&#39;s heavily done reinforcement it&#39;s not that much done so there is no programmatic ways of reinforcing that was systematic the kids so we implemented stamping charts kids could be getting all kind of rewards for doing these skills for doing effective behaviors and they loved it and also acknowledgement of some of the children who are doing better in DBT program and we we had a rising star which would be a child who did so much significantly better than you know from before or shining sorry this is the child who just success in DBT and we also have graduate group shoutout they know those that our graduate who actually helped with running DBT groups in the first level and kids love when other kids come in and teach and actually talk about their experiences I had one kid who really did not want to engage who really had difficulty engaging he was saying DBT sucks Donavan say DBT skills I&#39;m not talking about the CBT and then over time when he was about to get this church you know this child is that the mom one of my therapist is saying this child is sitting in a group and somebody else complaining the DBT sucks and he&#39;s like DBT is the best thing in the world everybody have to learn DBT you kidding me so you know you can actually get a shift that was like poster child for DBT and I wish I cannot have his photo saying DBT is okay okay so also milieu communication there was a big disconnect between milieu this is the staff on the floor and therapists and all of that and we needed to get them together and discussing and making sure that they all on the same page what is it that we&#39;re doing milieu was also not trained I is this something that I continue to struggle with and understand it&#39;s real life and I&#39;m having I&#39;m accepting it but I&#39;m having a hard time understanding how we can actually solve that effectively and very fast in my mind if not training beginner modification technique you cannot even look at a child in the professional capacity wouldn&#39;t you agree right Oh none of them are they have no idea what&#39;s reinforcement punishment extinction or whatever else is they don&#39;t know any of that how come you&#39;re doing an impression capacity you don&#39;t know they&#39;ll say your tools of the trade kidding me all right so I have to Train everybody everybody got trained and actually I also had to Train adjunctive stuff nursing interventionist because what happens a lot is child is cutting they go to nursing and nurses are like oh you poor thing what happened to you Oh Oh got a boo-boo okay though lay down watch TV I&#39;m gonna bring you dinner you know what I&#39;ll be cutting all the time okay so this is how our sample looks like uh we already had boys because there&#39;s not a lot of girls to randomize and okay so here we have a bit of a different numbers we have a lot of things going on you can understand those are the kids that cannot be managed at home we have ADHD disruptive behavior huge huge amount of numbers a lot of them more have like more than sixty percent three or more diagnoses and the you know full scale IQ you know not too I a lot of them have suicidal ideation and behavior huge amount of them psychiatric hospitalization a lot of them had been hospitalized four more times they start as young as seven and you know pretty much most of them had previous outpatient and setting as young as five okay a lot of them are on all kind of medications and thank you so much thank you so much Francesca we may have time for more than this question is how do you help kids differentiate what are real dangers from their emotional reactivity how kill them differentiate or don&#39;t help them tell the difference between whether their reaction to a real danger versus their having an emotional reactivity to something that may not be a real danger when you use that stop yes very good question so check the fact is this something that&#39;s real is the line charging it use about to eat you you have fear yeah don&#39;t stop and freeze anything okay what am I going to do is right now no no run however if there&#39;s a line that&#39;s in a cage and you still have phobia you know I have have to fear now your fear is not justified you have to stay there and expose right so you teach them to differentiate especially with children you need to have to be very concrete and does that influence the fight-or-flight response what does this why Reese when you when you teach them to freeze does that influence their fight-or-flight responses okay so freeze itself I don&#39;t think it influences the the it influences the reactivity right so they stop themselves from reacting fight and flight response you know as far as understand a sympathetic nervous system we have a lot of skills that are - are getting you know getting the parasympathetic nervous system to get activated what is this you know sympathetic is our fight-or-flight parasympathetic is the one in which you actually you know rest and digest there are lots of skill that we&#39;re teaching them that will activate parasympathetic nervous system meaning that they arousal will come down and they&#39;ll be able to think straight ER and be able to arrive at a solution as opposed to when they&#39;re discombobulated so I&#39;m not sure if I answer that one thank you no I I think that&#39;s helpful we have a couple of questions related to motivation and and getting kids to commit without eliciting defensiveness or them being resistant oh oh great great great okay so Marsha Linehan originally was telling everybody that everybody has to do you know be the other lessons whatever it is everybody has to do the skills that she&#39;s doing that she presented in the way that she is doing them the teacher knows can be different and then she turned and said Francesca that doesn&#39;t apply to you because she understands we&#39;re talking with kit we&#39;re talking about kids here and again I forgot about the question it was about dealing with resistance that might arise when you introduce yeah I don&#39;t know why I got Marsha went in and there okay so and okay I lost my train of thought resistance the motivation oh and the other thing that she told me that everybody has to commit in DBT except for what I do because some kids coming in that you know kicking and screaming don&#39;t want to be there in rally but they do we don&#39;t elicit commitment from kids if we see that the child is not going to make we just we just forget about it we need the commitment from the parent okay all right how young an age do you suggest ignoring the behavior thinking of babies infants as long as it&#39;s not a safety issue how young would you ignore as to not reinforce oh I ignore my all the time from very very is as soon as as soon as they were able to focus on me which probably will be different for one Arietta what would actually suggest but really with my kids especially with my son you know something is going on he&#39;s discombobulated he&#39;s running he&#39;s like he knows the drill okay mom come great job coming down get what happened all right now he&#39;s able to understand and connect you know I need to become my mom is long even going to give me attention if I&#39;m upset so as early as as I don&#39;t know one and a half I guess yeah again just not know research support can you please explain the difference between acceptance versus overindulgence when responding to temper tantrums Oh acceptance does not mean no change acceptance means that I&#39;m accepting that my child is having a tantrum times 10 to temper tantrum however I am in no way going to give it attention that&#39;s the change so there is absolutely no indulgence in terms of the temper tantrum there is a flexibility and built-in if child is crying because you know somebody didn&#39;t look at him right you know that&#39;s one thing you ignore that if child fell and scraped his knee and crying yes absolutely going to come there in a tenth there is you know which parent have to differentiate between is this something that&#39;s temper outbursts is or my child in the real danger or my child actually needs my support has nothing to do with attention seeking we have never questions about the diagnosis I think and his questions about is this also apply to kids who have more internalized instead of having temper tantrums how do you what about childhood bipolar how you tell the difference between that okay right so no in order for a child to be diagnosed with dmdd you know there&#39;s no in there&#39;s some internalizing but you know in terms of some of the feelings that they&#39;re having kind of suppressing some of the things but it&#39;s more of externalizing you know the behaviors that they have because this behaviors come from them not being able to regulate themselves so no it&#39;s not internalizing kids now in terms of difference between dmdd and bipolar disorder so in the night is there was this push to actually classify children that are now called dmdd as bipolar however people were able to recognize that this is a constant chronic thing the the eruptions it&#39;s not something that&#39;s intermittent that would be actually characteristic of a bipolar and would you speak to applying what you DBT for children to children who maybe don&#39;t have the tantrums but their their internalized they don&#39;t have they have other mood problems right right absolutely well there&#39;s research done right now with Tim in the England what&#39;s his name tip escape from the one who was you know who actually have Tom Lee Tim Lynch thank you Tim Lynch is doing internalizing DBT with internalized yes with adults absolutely right I haven&#39;t personally done it right this is something to look at while let me first see what Tim Lynch was able to do with internalizing and then we&#39;ll figure out what to do with myself well some of them are bipolar some of them deem DD it all depends on is it chronic or is an intermittent well the only well how to say it usually we don&#39;t diagnose children as having a personality disorder where you can&#39;t absolutely diagnose a child with personality disorder unless it&#39;s a social personality so which you cannot until they&#39;re 18 however is it really a personality disorder or a lot of it is a learned behavior in my mind a lot of this is a learned behavior what&#39;s there is my personality just sort of per se this is a disorder of emotional regulation that&#39;s built in this is something that they&#39;re born with yes they may be on the trajectory to develop point line personality sort of given their symptoms however I would not start there perhaps on that same vein there&#39;s a question here speaking to the neuroscience that you refer to and would it make more sense to call this a brain disorder is there possibility that DMD would also become state Tai&#39;s child what what&#39;s what&#39;s not a brain disorder mm-hmm oh really you know one of the research that&#39;s going on right now that I&#39;m really excited about you know it&#39;s not published yet kind of like trickle through the grapevine researchers at Harvard Harvard took several you know I think like 12 whatever volunteers and they have them do mindfulness practices for 20 minutes a day for about 20 day 12 days and they took Emma right before and after what they were able to find mind-boggling number one they were able to find that there is a increase in the gray matter in areas that are tension concentration problem solving memory after 20 minutes of mindfulness for 12 days and but I could predict that what I wasn&#39;t able to predict was that there is shrinking in the area that&#39;s fight and flight syndrome as fight in flight so meaning that this the fight and flight is shrinking the other one is expanding so you&#39;ll be able to regulate more and more effectively so yeah here we go I think this is getting to some of the understanding and reinforcement we have the tantrum is lying on the floor face down what is that and what to do we&#39;re thinking about it three-year-olds it&#39;s exactly the same thing ignore ignore ignore now acceptance validation all that stuff comes up either before temper outbursts when you&#39;re just catching the child may be getting into that emotion mind and you catch him right before and say Johnny I totally get it what just happened oh my gosh I got upset too okay can we now breathe together it&#39;s just calm down and then you cut it right then and there or after the tantrum is over child is the more or less normal mood then you process again starting with validation I told and said what happened you were feeling this because of that now the outcome did you like it no what can we do next time differently and then role-played don&#39;t just leave the child hanging there roleplay roleplay roleplay give actual points rewards whatever it is because you need to have behavioral rehearsal in it but one child is on the floor face down tantrum in there - for God there&#39;s no way you can actually do anything and he&#39;s gonna hear you and understand and process it and actually do something different plus you&#39;re going to give it attention so it&#39;s not effective and actually can reinforce the tantrum thank you so much [Applause] [Music]

okay so before you proceed I just want to disclose that my research has been funded by private foundations and an mah one thing that&amp;#39;s not there that I have to disclose that I&amp;#39;m a contracted trainer with behavioral tak and SF mentioned I started this work at Yale and staff was the one who started training me in DBT you&amp;#39;re my sensei and it has been amazing amazing I remember when Seth just started to train me and I was trying to get to adherence and DBT and that was you know taping all of my sessions and he was looking for them and the very first actually the second tape that he was able to see initially we had problems with sound and I&amp;#39;m sitting down here he&amp;#39;s telling me you know what I have one good news and what bad news the good news is we have sound the bad news it&amp;#39;s not DBT and you know what now I agree with him because now I understand what is involved in becoming a DBT therapist and I of course want to thank John Hoffman Lawrence Cahill Heather Douglas Paula Murray who are all here and say thank you so much for all of your support without your help and enthusiasm for what I do it will not be possible so of course I also want to thank people at my new home at well Cornell where I am under the wing of John walk-up Donald Nathanson my fabulous fabulous fabulous DBT therapist and I walk up who is my therapist as well she&amp;#39;s doing treatment as usual on the other side they actually here in the audience they told me if I ask them to wave they&amp;#39;re going to be mad at me so please wave all right yeah no I don&amp;#39;t see her okay so I also want to say thank you so much for the people at Green chimneys that&amp;#39;s one of the studies that I&amp;#39;m doing with children in residential care and they really did not know what they were getting themselves in when they invited me and say hey let&amp;#39;s build it up and it was supposed to be a one-year study we are year five now and I continue to tell them that we need to change change change and they continue to tell me yes we do some things are happening some things are not but this is reality okay I&amp;#39;m not attached to my slides there are many more of them more than I can actually cover in the talk most of them are for your information and and of course you can ask me whatever questions you&amp;#39;d like on anything that I&amp;#39;m missing and I&amp;#39;ll be available throughout the conference and you can also email me my email be at the end of my slides so we&amp;#39;ll talk a little bit about what DBT is all about I&amp;#39;ll tell you how I was able to adapt it to children and some of the very preliminary look at what the children look like unfortunately I don&amp;#39;t have the results yet I was working feverishly one of my studies active treatment is done but we were not able to get the data and fortunately in today if this conference was tomorrow then yes but not today I know a Matisse okay so DBT overview I can&amp;#39;t go too much detail with DBT is all about how many of you know what DBT is okay fantastic all right okay so for those who don&amp;#39;t DBT is behavioral DBT is cognitive but this is so much more above and beyond that and the main thing that I want you to remember is DBT is about balance it&amp;#39;s about balance between acceptance and change and everything that we do in DBT in so in terms of skills training or in terms of the strategies and procedures that therapists are involving and using it&amp;#39;s all either falling on the acceptance or the change continuing why acceptance is so important because if you don&amp;#39;t accept that they have a problem there&amp;#39;s no change one of the examples that I really like on this alcoholic anonymous the very first thing that a person does is what they stand up and they say what I&amp;#39;m John Doe and I am an thank you why is that important person accepted I&amp;#39;m here because I have a problem and therefore change is possible people with substance use alcohol abuse what do they say usually if they don&amp;#39;t haven&amp;#39;t accepted it yet I have no problem kidding me I can quit like this tomorrow on that you know yeah that&amp;#39;s not an issue for me so if there is no acceptance what kind of change is possible what are we doing with that if you&amp;#39;re just talking about acceptance acceptance acceptance alright that&amp;#39;s actually okay if you&amp;#39;re just talking if you&amp;#39;re just accepting if you just there for the client if you&amp;#39;re just giving in validation and understanding Klein is going to continue to come however at some point Klein will still start experiencing high level of arousal and sense out of control and will feel invalidated because yes you understand me but you haven&amp;#39;t helped me to resolve anything it didn&amp;#39;t help me to change if you just focus on the change and tell him you know there are some of the issues we need to resolve them how we&amp;#39;re going to do it again high sense of arousal feeling of out of control no collaboration no learning because what is what&amp;#39;s going on there is that the therapist is assuming that in validating role of saying you have a problem you need to change this is pretty much what they have been hearing since they were very little right parents telling them you have a problem what&amp;#39;s going on you need to change so acceptance is extremely extremely important not only from the therapist clients are learning to accept themselves and accept their issues before they can proceed to changing them what is our main target in DBT is of course emotion regulation and what are the tasks we want to decrease mood dependent behaviors we want to help them reorient the tension and very importantly organize their attention in the service of their goals now what Emery era was talking about in the previous presentation she was talking about this invalidating environment the mothers who are having difficulties raising their children and they may be doing things that is not helping the child to get you know to get where they need to be and actually may prevent them to get to the well-being say that they want them to be what in DBT we have a biosocial theory in which we&amp;#39;re saying you know what what it is it&amp;#39;s a combination between the biological predisposition to experience emotions in a different level the sensitivity to the emotions the vulnerability and it&amp;#39;s in boring and then the child who is that sensitive and vulnerable is born into the environment that cannot help and support that and it may not necessarily be an environment that is actually abusive or neglectful now yes it can also happen but we&amp;#39;re talking about here it&amp;#39;s a mismatch between what the child needs and what the parents can give they can&amp;#39;t match the needs and I don&amp;#39;t see it at the theory for me this is an everyday occurrence what I see with my clients and you know what some of the self disclosure I have to say is that I have two kids I have a 16 year old daughter and I have a nine year old son they&amp;#39;re diametrically opposed different my my daughter is like a duck in the waters everything just rolls down a feather she&amp;#39;s very resilient if you want to call it that my son he&amp;#39;s the sensitive one he is the one who would be like I have a cut I&amp;#39;m gonna die and he actually thinks that he actually feels it it&amp;#39;s not dramatic if he&amp;#39;s like histrionic it&amp;#39;s this is this is the level of fear and emotion that he has and oh boy am I happy that I was ready to actually know what to do it with such a sensitive child because what is going on with children who are born sensitive is that they indeed have very easily activated arousal meaning that little things for us maybe not even noticeable activate them and they react very very strongly somebody didn&amp;#39;t look at me right somebody didn&amp;#39;t say hi I dropped my toy in it cracked whatever it may be and now the child will just go pass it and not notice this chat will have a huge outburst and it will be very hard for that child to calm down and sometimes we may not even understand what&amp;#39;s going on we may think that it comes out from nowhere well you know what something is going on inside that child some thoughts them feeling some memories something and environment make you it boom there is an outburst so these children go from one to hundred pretty much in zero time a lot of the times and it&amp;#39;s very hard for them to stop and then we couple it with what we call in an invalid dating environment and again don&amp;#39;t be treated by the name all that means that again not necessarily abuse and neglect parents don&amp;#39;t know what to do with this kid they feel trapped because these kids don&amp;#39;t come with instructions none of them come but these kids particularly need them and what happens is the parent is saying oh my god what&amp;#39;s wrong with you why can you just stop why are you reacting so much to such a small thing why can&amp;#39;t you be just like your brother come on just stop it just snap out of it and from all of that what happens is chronic emotional dysregulation one of the things that I want to also say that that the environmentally brain is that a lot of the times when child is having the outbursts the environment is not going to respond or respond and not an in the way that&amp;#39;s supportive and then child learns that you know what if I have a severe outburst that involves me saying I&amp;#39;m going to kill myself I&amp;#39;m actually you know what everybody comes running so environment can actually also support extreme extreme expression of the emotion so what we have out of that is an ability to understand and label their emotions because everybody&amp;#39;s saying by angry not supposed to be angry why are you feeling angry no I don&amp;#39;t feel angry well child is like okay I guess I&amp;#39;m not feeling angry so kid is really confused now they can of course modulate the emotional reactions because maybe parents aren&amp;#39;t themselves not sensitive and they have never learned how to deal with them and how they supposed to understand the child and teach the child how to modulate their emotions they&amp;#39;re clueless ybb team there&amp;#39;s huge amount of empirical research right now on its effectiveness in tackling exactly what we need the emotional regulation and it has been you know have such such an incredible empirical support in the literature for adults Alec Muller that it&amp;#39;s with adolescents with high degree of success and they&amp;#39;re all kind of studies supporting what it&amp;#39;s doing to the brain activity so I&amp;#39;m not going to go into that however what I want to say is that if you&amp;#39;re think about a sensitive child who has what&amp;#39;s now in dsm-5 called disruptive mood dysregulation disorder we&amp;#39;ll talk about this a little bit later in my view you know I would not be surprised if research shows over time the children with disruptive mood dysregulation disorder some of them are on a trajectory to have borderline personality disorder later in life just like children with conduct disorder and some of them are in trajectory to develop antisocial personality disorder because a lot of things that we see with children with severe sensitivity and vulnerability is what exhibited by patients with borderline personality disorder you know a lot of kind of either-or thinking suicidality behaviors extreme expressions of emotions it&amp;#39;s all there so what did we do to adapt DBT for children again you have a lot of slides there that I will not cover in detail there for your information and I will be very very happy to answer your questions either today or over the email some of the things that were added to the DBT model we needed to make sure that children can actually understand what emotions are we needed to make sure that parents can understand what the emotions are why they why we need it we needed to understand how they start how to what to do with them and how they&amp;#39;re different from thoughts and behaviors so we added didactic on emotions to the individual part some of the skills have been changed simplified condensed and you&amp;#39;ll see a bit later that we even have different acronyms here&amp;#39;s some of the handouts stop scale this is something that has been developed for DBT for children to help them stop the reactivity in the moment the impulsive behaviors in response to distress actual marsha linehan really liked that scale and now it is also a part of DBT for adults so what that is just to give you an example of how we do it with kids stop is an acronym S stands for stop freeze don&amp;#39;t move a muscle if you indeed can do that 70% 80% of your problem is solved because you&amp;#39;re indeed we&amp;#39;re able to become aware that you&amp;#39;re about to react and if you react it&amp;#39;s not going to make it better may actually make it worse you are willing to actually stop meaning that you&amp;#39;ll be willing to do something different about it then the rest of this is you take a step back you detach them from the situation a little bit you&amp;#39;re breathing in and out to calm down then you&amp;#39;re much more ready to observe what&amp;#39;s going on inside and outside of you you need the information and then once you have this information little bit calmer you did hatched you didn&amp;#39;t react now we can proceed mindfully you can ask your wise mind what to do depending on your goals so how do you do that you train the practice roleplay a lot every day instructing parents you have to do a lot of hypothetical situations in which the child will may be reacting and you want to instruct him to freeze and we give all kind of rewards at the end of it even if it&amp;#39;s hypothetical so the more parents are able to roleplay hypothetical situations the higher the probability because it&amp;#39;s a behavioral rehearsal the child will actually be able to stop and freeze in the moment when they are to become dysregulated it&amp;#39;s very important practice practice practice is born for everybody for children triple importance well I&amp;#39;m not going to go again in depth what we did to adapt as I said we simplified them all four modules are there mindfulness and personal effectiveness and motion regulation distress tolerance everything is there these acronyms a little bit different and more child oriented some of the handouts on the skills opposite action alright the three had a dragon of chain analysis so chin analysis chain and solution analysis and DBT is something that is staple trying to figure out what is it that happen and what to do instead it&amp;#39;s quite a difficult thing to do with adults they don&amp;#39;t like doing it and sometimes it&amp;#39;s so toxic that therapists collude would decline not to do chain analysis so therapists have to be really careful to really understand the reinforcements that are going on the negative the positive they&amp;#39;re so because their behaviors are also being reinforced by the client reactions well anything that we do with kids the easiest way to teach it through games right so this is a game and people are asking me how did you come up with a three-headed dragon I said well was easy for me all dragons and Russia have three heads it&amp;#39;s a Russian dragon how do you use it alright emotion wave everything starts with event emotions don&amp;#39;t come about by themselves something has to trigger them so emotion wave is event then not feeling interpretation of the event because that interpretation can can can make a difference in in terms of how you feel about the event then the feeling the cup brings in all kind of sensations urges to to act such as when you&amp;#39;re angry you want to do what yell fights grad fight right and this is the action urge now you don&amp;#39;t have to do it you&amp;#39;re not your emotion you may actually say to yourself you know what this what emotion is telling me to do however in that situation that&amp;#39;s not going to be effective for me to move to actually do it what tells me to do so then you have action whether or not you&amp;#39;re going with the emotion depending on the situation the action urge and then of course the after effects positive negative consequences more thoughts behaviors are the people saying and doing things and all of that can start all new wave and that&amp;#39;s very important to remember because how long do you think one emotion lasts one one discrete emotion yes five seconds all right two minutes all right so one discrete emotion lasts about 40 seconds when I tell it to cry and they say what are you talking about I&amp;#39;ve been mad for three weeks now then since that happened telling me it&amp;#39;s 40 seconds as a yes it&amp;#39;s 40 seconds because what happened was you had one emotion anger and then you start eliminating you start doing things that anger wants you to do fights scream you know you know send texts that are angry you know whatever it is that you&amp;#39;re doing and then that one discrete emotion turns into what you mean the same emotion here we have a mood all right so you know all of these things are actually what I&amp;#39;m describing giving you a sample of what we talk with children when we&amp;#39;re doing didactics on emotions so we&amp;#39;re using our wave paradigm in terms of how emotions comes up when we do the Dragon game all right for example event a boy called me names thought you know what he hates me and you know what happens people who have such strong emotions they take their thoughts and feelings and they take them underneath and they actually think of them as facts that&amp;#39;s why you know check your facts thing and dbj of course feeling of anger it&amp;#39;s a fact he hates me now what&amp;#39;s the urge to kick him what did actually happen I did kick him and I got into detention and then you say did it go okay you know what I totally understand why you would feel angry somebody calls your name names I would feel angry too we call it thank you validation all right very important staple we need to have validation that&amp;#39;s one of the acceptances strategies geez did you like the outcome the detention did you like to get into detention no all right so what do you want to do with that next time somebody calls your name what are you gonna do do you want to think of something different yeah then what we do we interrupt the urge and the action by our stop skill you have a feeling have an urge freeze don&amp;#39;t move a muscle all right what I&amp;#39;m gonna do here and I am going to maybe go and tell a teacher after I stop them freezed that&amp;#39;s one solution another solute and then the after effect would be you know I would get praised I&amp;#39;ll feel proud of myself you know what I&amp;#39;m the boss of myself that&amp;#39;s one of the goals that we have for these kids to be the boss of themselves and of course they want to be proud and want everybody proud of them now another solution we always need a backup walk away and what will happen is again feeling proud of myself you know situation did not you know at first maybe even cut better all right so this is pretty much the chain analysis in a very simplistic way and you can go higher and higher you know with with all those cards and this is actually a game you know it&amp;#39;s a huge poster you know with its magnet receptive materials so you know the little carts were placed on it you know we&amp;#39;ll write all of this out with the child and and then you know we actually sometimes write it on the sheet of paper so the children can take it back and look at it next time do you they need to figure out what to do okay so there&amp;#39;s some of the things that we came up with in terms of using the skills sometimes children would stop and freeze and then they kind of like okay how do I proceed mindfully what do I do they make I kind of get stuck because there&amp;#39;s still emotional and this is something that we came up with was it&amp;#39;s it&amp;#39;s it&amp;#39;s skills we&amp;#39;ll what you do is it&amp;#39;s this actual skills rules from some of my clients you have a will and you you know the are your favorite skills you put there and you just flip the error and whatever it ends and it lands on you have to do it simple enough and also introduces the game in it in some fun okay so diary card absolutely children I don&amp;#39;t care it&amp;#39;s diary card we need to have it and of course we&amp;#39;re not expecting that the child is going to be able to do this without a parent we actually not expecting the child is going to be able to do any of this without a parent I&amp;#39;ll talk about this more so parents are there to help them what we&amp;#39;re tracking is emotions we&amp;#39;re trading suicidality self-harm we&amp;#39;re tracking ineffective behaviors such as depression destructive behaviors were tracking effective behaviors absolutely such as ignoring walking you or whatever it is and then we&amp;#39;re looking at which skills they were able to use throughout the week Wow parent training component well you know what DBT is not an individual therapy for a child absolutely not it&amp;#39;s a family therapy the more you do it the more I realize that it&amp;#39;s a family therapy because otherwise it&amp;#39;s like doing couples therapy with seeing individually separately you can&amp;#39;t do that you need the diet there sometimes I do child&amp;#39;s up assist a child separately for the individual however a lot of the time especially if the child is is is like seven eight nine I do absolutely you know most of the time have a parent in there because it&amp;#39;s a problem in the relationship that we need to resolve and the parent beings there that&amp;#39;s that&amp;#39;s the child&amp;#39;s world that&amp;#39;s where they&amp;#39;re coming from that&amp;#39;s that&amp;#39;s the environment you know the validating or invalidating environment that can actually support the child or get the child in a position that they&amp;#39;re going to be more and more dysregulated now keep telling my parents you know what there are there&amp;#39;s absolutely no way I&amp;#39;m going to see that child if you don&amp;#39;t commit to doing it with him full force four cardinal rules of parenting in my mind number one they&amp;#39;re very simple and very hard to do number one model the behaviors you want how you expect your child not to scream kick and fight if something comes up you&amp;#39;re upset you scream at your kid or you physically punish them absolutely can&amp;#39;t and then sometimes parents are telling me well yeah but it&amp;#39;s so hard to ignore them because I feel so upset when they do this and that and I say absolutely it&amp;#39;s very very hard are you kidding me I&amp;#39;m a parent I know what it looks like you think I don&amp;#39;t want to throw my kids out of the balcony yeah sometimes they do it&amp;#39;s very very hard and on the other hand listen we&amp;#39;re asking you seven-year-old to learn all of these skills so the key can be in control of his emotions and you&amp;#39;re telling me that you or forty-five-year-old cannot do it because it&amp;#39;s hard please you have to understand whatever behaviors you model that&amp;#39;s the behaviors the child is going to do parents come in a lot of the time with an expectation that child should be polite should be respectful should be following directions right away bla bla bla bla and they&amp;#39;re shocked when I tell them absolutely not child should not do any of that none you reinforce it they do it you don&amp;#39;t they don&amp;#39;t do it simple as that what our shoots shoot same position in reality this is the picture that we draw of how we want things to be and then we impose it on reality in matching and then we continue to pose and impose it imagine that we&amp;#39;re continuing to make us ourselves very very upset and what happens with that is that we turn pain into suffering what is the difference first thing that I want to say is sometimes parents you know coming in and say I can do it you know this this is very hard you know what this is is that we have a delusion and it&amp;#39;s truly a delusion not my words this is marshal in hands words that we cannot tolerate pain yes we can pain is an integral natural part of our lives we need to have it because if you&amp;#39;re sitting at the beach sipping pina colada you&amp;#39;re not learning anything right it&amp;#39;s very very important to relax however there is no challenge that are presented to you that you need to overcome and solve and if you do overcome and solve them you progress to the next level of mastery understanding and learning if you hide away if you run from them if you avoid what happens is you turn that pain into suffering suffering is pain plus not accepting of that pain because of that delusion that we can&amp;#39;t tolerate it parent who is giving in to the child temper outbursts in a store because they can&amp;#39;t accept the pain of child screaming and they and everybody is looking at them and judging them and thinking what a bad parent you know you are and they said have it stop it just stop it you know what that that parent was not able to tolerate that pain in the moment now they turned their pain into suffering because every time child was that kid in the store you bet he&amp;#39;s gonna do it and it&amp;#39;s going to be very hard to extinguish one of the things we teach a lot of the things that we&amp;#39;re teaching it&amp;#39;s very important for them to understand that they need to accept their child as the child is there&amp;#39;s nothing there are no bad people a good people we are all people that&amp;#39;s it parents always ask me how I&amp;#39;m able to tolerate their children in the session because they are bouncing off the walls really well I have several answers to that the first one is that I have my hierarchy of what I want to do you know me having that child sit in the chair quietly and that&amp;#39;s my whole time spent on getting in that chair you know that&amp;#39;s not worth it I want him to learn I want him to listen if he&amp;#39;s bouncing off the wall but he&amp;#39;s answering my questions and I know that he&amp;#39;s processing and understanding that&amp;#39;s it I don&amp;#39;t care number one number two I accept I accept another judge it&amp;#39;s a child you know he&amp;#39;s doing it you know because there is some kind of a function to that behavior very important what is the function of behavior if you can accept child for what they are not judge them because a lot of the times parents are sitting there and judging the child and judging themselves oh my god she&amp;#39;s gonna think I&amp;#39;m a horrible parent oh my gosh she&amp;#39;s gonna think my child is so you know bad behaved and and they get discombobulated with that and they can&amp;#39;t tolerate it and they look at me I&amp;#39;m like so relaxed and he&amp;#39;s like making grounds on my head and throwing things and whatever you know it is what it is but I&amp;#39;m sitting there I&amp;#39;m not just staring at the wall I am figuring out why is the child doing this and how can I help this child do differently if you have that bowl as opposed to continuing to judge and like be tense about this two different ways of handling the situation okay so function of the behavior is extremely important very good example one of my mother&amp;#39;s five kids single parent one of her daughters is very aggressive to the siblings she is kicking screaming taking their toys whatever it is what the mother is doing whenever she&amp;#39;s aggressive for this you know it for the safety of the other kids she grabs that child drags her to different room restrains her and starts telling her to calm down well was the function of the behavior what do you think exactly can you imagine five kids this mom doesn&amp;#39;t have time for all of them you know to the degree that they may want so this kids you know was actually using that behavior to get that hug to get that mom to themselves so hypothesis you know what maybe that&amp;#39;s the function of the behavior let&amp;#39;s test it you&amp;#39;re going to get the child the child is going to get exactly the same thing by you by yourself in the room hugging talking whatever it is for poor social behaviors such as sharing being nice to their to the siblings you know talking nice that whatever it is you know what solved I could have thrown all kind of skills to that child walk away when you work of you know provoked by your sibling you know when they take your toy breathe whatever it is I could have reinforced every time she would go away and it&amp;#39;s not gonna be consistent it would not stay it would not be maintained or be very useful maybe sometimes because the function is not solved you figure out the function figure out how to solve it in a different way you&amp;#39;re done a lot of what we&amp;#39;re doing we&amp;#39;re talking about side-effects of punishments we&amp;#39;re talking about the dialectic of parenting I&amp;#39;m not going to go into any of that it got a taste of this here and there what I want to make sure that that you understand that what we do a lot of it is not necessarily teaching the what to do with the behavior the change a lot of our work is on helping the parent accept accept the child and accept themselves and when we talk about the function of the behavior so that the parents will instead of getting discombobulated about their child being bad they wouldn t be able to actually figure out what the function of the behavior is and how does how to help that kid get that function and just just the other day oh my god it&amp;#39;s a great story just the other day I have this nine-year-old who is sitting there and he thinks that his mother hates him and you know what his mom doesn&amp;#39;t hate him but that&amp;#39;s exactly what she exhibits with the way she talks to him with the way she screams at him with the way she&amp;#39;s comparing him to siblings and so forth so on and this nine-year-old is sitting there and you know I&amp;#39;m talking to him saying you know what he must be feeling very sad thinking that your mom hates me and this nine-year-old looks at me and he&amp;#39;s saying I&amp;#39;m not sad I am ashamed I&amp;#39;m you know who&amp;#39;s ashamed of himself on that level he can actually understand and verbalize it ashamed that he&amp;#39;s not good enough because he&amp;#39;s continually getting that message being screamed at it being told what I&amp;#39;m doing is wrong what I&amp;#39;m feeling is wrong what I&amp;#39;m thinking is wrong everybody else around me or better I cannot control myself what are they supposed to think about themselves absolutely that deep deep shame and you know what comes from deep shame one of the functions of the behavior that we&amp;#39;re seeing Chuck was miserable wouldn&amp;#39;t want to make the parent miserable one of the functions when you understand that you first need to start repairing the relationship you can&amp;#39;t teach skills and blah blah blah no no you have to step back and say okay you need to pair the relationship in a way that&amp;#39;s going to actually be helpful in and support all of the what we&amp;#39;re going to be doing in top of it we want the child to actually want to be reinforced by the parent when the child to be around the parent on the child to look up to the parent and want to please them as opposed to make them miserable if we have that excellent we can really capitalize on that that&amp;#39;s why I continue to tell parents the cardinal rules of parenting model all the behaviors you want number one number two if you don&amp;#39;t like the behavior how whatever it is name-calling swearing whatever it is as soon as it&amp;#39;s not safe it&amp;#39;s not as soon as it does not have any problems with safety to the child or somebody else of property ignore ignore ignore very hard to do well you know what you have all those skills you know use your skills you can or you like the behavior reinforce it parents don&amp;#39;t do it you know a lot of the times their attention is actually dragged to the negative because this is very very understandable our emotion mind somebody is screaming you we turn to that and we actually want to do something about it you know how many times do you have you seen children sitting on the floor playing together nicely parent coming in and saying oh my god guys I&amp;#39;m so happiness playing so nicely together great job I&amp;#39;m gonna get two cookies and milk and whatever you know it&amp;#39;s a quiet okay I&amp;#39;m going to go so as soon as kids stop squabbling what happens what&amp;#39;s going on here why did you do that what did you say there&amp;#39;s so much attention paid what do you want one of the functions of the behavior kids got reinforced by attention by doing for doing what they&amp;#39;re doing they&amp;#39;re not manipulative not pushing buttons they&amp;#39;d be heated that reinforced because that&amp;#39;s that&amp;#39;s how they know how to get what they want they have a temper tantrum parent can take it because apparently we cannot tolerate pain right and then they give them whatever the chat once boom child learned all right that&amp;#39;s what I need to do next time so what does the parent want okay so we have modeled the behavior you want reinforce what you like every little thing because the reinforcement doesn&amp;#39;t happen because of the shoots why should it be reinforcing my child for being polite he should be that or being respectful he should be that or for following directions he should do that right no he should do nothing and the fourth one is play with the kids have fun with them if you have a child who actually enjoys your company how much more reinforcing your place is going to be how much actually he&amp;#39;ll be looking up to and want to spend time with you and would want to make you feel proud and happy instead of miserable so he think I want to come home after a whole day of clients bouncing off the wall and playing nerf gun with my nine year old running around the house shooting no or watch anime with my daughter on YouTube oh my god scare me it&amp;#39;s what I do because that&amp;#39;s what they like and I want to share in that and they look and they&amp;#39;re waiting for me to come home because I&amp;#39;m the one who&amp;#39;s actually taking their interests seriously and you know what I have very very very minimal problems with my kids my daughter only had three temper outbursts in her entire life she was three she knew how to execute them perfectly I am NOT a germaphobe however I actually don&amp;#39;t like when my three-year-old is on the floor in a shopping mall doing this and I have to stand not look the three monkeys you can look can hear can talk perfect image of ignoring stand there and think oh my god what kind of bubonic plague she&amp;#39;s gonna bring and I have to take her to the emergency room right now after this so but I was able to tolerate that and then BOOM after three times trying she learned an air mom in budging so that&amp;#39;s what we&amp;#39;re hopefully going to instill in our parents but to do any of that they need to first accept and let go and see their children for what they are human beings with behaviors that I learned and the learning is there and we need to help them to learn something different to get to their goals alright I&amp;#39;m not going to go through the slides how much more time do I have to go oh my gosh alright current research on DBT this is my wonderful outpatient research team Donald Nathanson wave ha Amy Caitlyn and me over there oh did the dragon remember we talked about the dragon alright so this research is with children with disruptive mood dysregulation disorder very neat clear-cut study only kids with dmdd what&amp;#39;s team did he multiple at least three behavioral outbursts that are not in proportion to the situation he didn&amp;#39;t look at me right I have a temper outburst for an hour or my client yesterday she got a portion of ice cream that was smaller that she wanted she had an outburst I think for five or six hours with kicking the car taking the mom running into the streets you know the whole gamut of things and in between of the of the outbursts the child exhibits irritable angry mood so I just want to make sure that we understand these are not kinda kids there&amp;#39;s a completely different breed of kids they&amp;#39;re sensitive kids they are not the one who are aggressive and they&amp;#39;re and they are proactive they&amp;#39;re not the predatory type they look on the disorder they are reactive type they are reactive time because emotions feel different to them we may not be able to appreciate what emotions feel to them because if what we experience emotions from one maybe to five they go straight to 10 it&amp;#39;s so overwhelming it&amp;#39;s almost toxic they can&amp;#39;t contain it it spills out ok so this study 44 kids oh my god as Donald how we got there it&amp;#39;s all him all him or him thank you so much and 22 in each condition its DBT for children versus treatment as usual whatever is usually right now delivered at Cornell and my studies we&amp;#39;re just starting to do DBT with kids so the studies that I&amp;#39;m doing are going to stage one visibility and maybe some preliminary efficacy but what we want to see is can we do it with pre-adolescent kids can they understand it can they use it again their parents do it can we do it in the format that we&amp;#39;re doing it because it&amp;#39;s a little bit different from the usual the format is so this is this is the inclusion criteria and the format is in a way that we need to do sessions with the child and the parent in it so we can have child coming in by themselves we absolutely need to have a parent component in it because the parent needs to learn then we want everything that I said about you know their their own reactions to the kid and how to modify they also need to learn what the skills are so that they can model them themselves they can prompt the use of skills from the child they can coach the child and the use of skills so they have to be there 100% and the way we did it is that everything that we&amp;#39;re teaching didactically to the child will be that skills be the didactic of emotions parent are absolutely have to be there also parents receiving their separate training in behavior modification techniques and validation techniques and I&amp;#39;d ended at techsan what is the dialectics on parenting and they&amp;#39;re receiving skills training together so session in the outpatient looks like they&amp;#39;re well again you know it&amp;#39;s a function of a form and DBT nothing is set in stone 30 minutes with the child 20 minutes with the parent 40 minutes with skills and then you mix and match whatever you need to do okay the other challenge was skills training the skills training in DBT for adults and adolescents is groups you know what put in a group seven-year-old with a thirteen-year-old what are you gonna get and parents on top of it nobody&amp;#39;s getting anything right you really need to be very careful because the developmental levels the cognitive levels are so different you really have to understand your population and really have to do it on the individual basis that&amp;#39;s why the skills training is in there you know within the individual therapy well this child is not just behaving that way at home schools are also a big part of this remember dmdd is at least two settings so we&amp;#39;ll always have something else going on outside the house and you know we always have to figure out how to approach the schools and do programs in the school settings and that&amp;#39;s actually quite challenging on some levels and on some levels it&amp;#39;s very rewarding because you can see how the teachers are starting to understand the concept that we&amp;#39;re teaching and some of the teachers are telling me you know what I use this on all the kids down this is fantastic thank you so much for teaching me this okay so DBT for kids is the 26 sessions but again sessions with its topics you can deliver them so far in 32 week format whichever way you want it treatments usual is pretty much exactly the same twenty six sessions but they can go all the way to 32 weeks and then we have three months follow up with some booster sessions in between one two booster sessions per months and this is clinical side this is well Carnell and your presbyterian okay so what our look kids look like we have pretty good split between merino males and females most of them Caucasian hiya CS also parents are reporting a psychopathology themselves high education no high level of education in the family and third of them actually got parenting training which I don&amp;#39;t know what kind of parents were training it was because most of them coming in and telling me yeah I&amp;#39;m doing point chart but it ain&amp;#39;t working because there ain&amp;#39;t doing it right this is what they are look like in terms of diagnosis we have a lot of ADHD actually lower than I would explode then I would be expecting but pretty much their anxiety disorders interesting you see we in our samples you know as opposed to what literature shows we did not have anybody with diagnosed depressive disorder outside of the dmdd and which is absolutely understandable none of them are also diagnosed with conduct disorder which actually can as per the diagnostic manual II can have a bit scammer ability but in my mind there are like two things on the opposite extremes you know reactive and proactive aggression and you know a lot of them had multiple diagnoses actually half of them now when I talked to you program officers in Grand you know NIH whatever it is they keep asking me so why do you need to do DBT this is so big and this like you know so complicated do the excuse actually need it are you kidding me no and I say seven-year-old more than 50% suicide I didn&amp;#39;t sell calm seven-year-old eight-year-old nine-year-old you know where they&amp;#39;re going with that trajectory yeah we need this alright well it was interesting when we&amp;#39;re starting assessing those kids this something that we haven&amp;#39;t been starting to do at the very beginning of the study but we added that measure because parents were telling us our child has sensory processing issues with sounds taste touch either than with their siblings and when we actually incorporated into it into the assessment we saw that yeah you know t-scores this is the kind of like a 70 and above is severe problem and some problems you know up to 70 so a lot of them are either some problems in sensory processing or definite dysfunction in sensory processing meaning that there&amp;#39;s something in the brain the sensitivity is spread out its physical sensitivity and emotional sensitivity it&amp;#39;s very very interesting I was very excited about that yep they all have definitely serious you know you know issues with functioning on sea gas a lot of them had previous outpatient therapy some had hospitalizations and almost half of them have special services at school like one-on-one people who are following them around or special schools or whatever it is because they&amp;#39;re very hard to maintain them in the community now they are on medication yep and a lot of them are actually on stimulus with Hannibal you know ADHD and here&amp;#39;s the breakdown so some of them actually more than one or two meds okay DBT see for children in residential care so this is my crew in green chimneys residential care fantastic fabulous therapists I love working with them they were so hungry because they were feeling overwhelmed didn&amp;#39;t know what to do with these kids you imagine and they&amp;#39;re really jumped in with both feet and eat it up so there we have 47 cases 27 DBT and 20 in treatment as usual and our inclusion cream this is much messier study remember that one dmdd very clear-cut this is pretty much everybody unless they have mental retardation and well look at that we have very low threshold what we call mental retardation so a lot of them have come of problems unless they have PDD or psychosis or bipolar they&amp;#39;re in so we have a lot of variability there so I I don&amp;#39;t know what that date is going to look like and again our main issue was to figure out can we do it can we build a program like that in residential care for children well will they be coming will they be accepting and then the second question is you know what the benefits are okay so it&amp;#39;s pretty much very similar 26 individuals to 26 skills training session now remember DBT function of a form here we can actually do group trainings and skills because these children are by units by age so we have lots of 7 8 year-olds in one unit and you know so forth so we can actually do it it&amp;#39;s programmatically possible infeasible to do group you know skills training with kids now when I moved into that doing the studying residential care at Green chimneys I moved in very opportune time because at that point they were constructing new dorms and I was actually able to randomize kids TBT dorm to u-dor separate staff separate therapists fantastic because otherwise what are you gonna do put a dot on the child&amp;#39;s head and said you treat that one with the dot this way and without it the other way not possible it&amp;#39;s a very rare opportunity I&amp;#39;m very very grateful to Green Teams to inviting me and actually long need to do this now you know this is a treatment as usual that they&amp;#39;re doing now some of the challenges there is that they&amp;#39;re there for two or more years you know they continue to you know have the same DBT group all over and over again and some of them don&amp;#39;t need it anymore so what do you do well we actually do a levels of groups so newcomers at least you need to have at least two rounds of DBT so it&amp;#39;s full year of DBT and then if they actually did that they either go to pre graduate the Graduate pre-graduate children completed all of that two rounds of DBT skills training however they still continue to struggle to implement it then we&amp;#39;re doing pre graduate when it&amp;#39;s DBT heavy with an application actual application to the dorm in their lives and then the graduate group it&amp;#39;s talking about this church and talking about you know real life TBT in real life what would they need to do how would they need to use those skills outside of the program the other one was reinforcement ah just like with parents punishment something that&amp;#39;s heavily done reinforcement it&amp;#39;s not that much done so there is no programmatic ways of reinforcing that was systematic the kids so we implemented stamping charts kids could be getting all kind of rewards for doing these skills for doing effective behaviors and they loved it and also acknowledgement of some of the children who are doing better in DBT program and we we had a rising star which would be a child who did so much significantly better than you know from before or shining sorry this is the child who just success in DBT and we also have graduate group shoutout they know those that our graduate who actually helped with running DBT groups in the first level and kids love when other kids come in and teach and actually talk about their experiences I had one kid who really did not want to engage who really had difficulty engaging he was saying DBT sucks Donavan say DBT skills I&amp;#39;m not talking about the CBT and then over time when he was about to get this church you know this child is that the mom one of my therapist is saying this child is sitting in a group and somebody else complaining the DBT sucks and he&amp;#39;s like DBT is the best thing in the world everybody have to learn DBT you kidding me so you know you can actually get a shift that was like poster child for DBT and I wish I cannot have his photo saying DBT is okay okay so also milieu communication there was a big disconnect between milieu this is the staff on the floor and therapists and all of that and we needed to get them together and discussing and making sure that they all on the same page what is it that we&amp;#39;re doing milieu was also not trained I is this something that I continue to struggle with and understand it&amp;#39;s real life and I&amp;#39;m having I&amp;#39;m accepting it but I&amp;#39;m having a hard time understanding how we can actually solve that effectively and very fast in my mind if not training beginner modification technique you cannot even look at a child in the professional capacity wouldn&amp;#39;t you agree right Oh none of them are they have no idea what&amp;#39;s reinforcement punishment extinction or whatever else is they don&amp;#39;t know any of that how come you&amp;#39;re doing an impression capacity you don&amp;#39;t know they&amp;#39;ll say your tools of the trade kidding me all right so I have to Train everybody everybody got trained and actually I also had to Train adjunctive stuff nursing interventionist because what happens a lot is child is cutting they go to nursing and nurses are like oh you poor thing what happened to you Oh Oh got a boo-boo okay though lay down watch TV I&amp;#39;m gonna bring you dinner you know what I&amp;#39;ll be cutting all the time okay so this is how our sample looks like uh we already had boys because there&amp;#39;s not a lot of girls to randomize and okay so here we have a bit of a different numbers we have a lot of things going on you can understand those are the kids that cannot be managed at home we have ADHD disruptive behavior huge huge amount of numbers a lot of them more have like more than sixty percent three or more diagnoses and the you know full scale IQ you know not too I a lot of them have suicidal ideation and behavior huge amount of them psychiatric hospitalization a lot of them had been hospitalized four more times they start as young as seven and you know pretty much most of them had previous outpatient and setting as young as five okay a lot of them are on all kind of medications and thank you so much thank you so much Francesca we may have time for more than this question is how do you help kids differentiate what are real dangers from their emotional reactivity how kill them differentiate or don&amp;#39;t help them tell the difference between whether their reaction to a real danger versus their having an emotional reactivity to something that may not be a real danger when you use that stop yes very good question so check the fact is this something that&amp;#39;s real is the line charging it use about to eat you you have fear yeah don&amp;#39;t stop and freeze anything okay what am I going to do is right now no no run however if there&amp;#39;s a line that&amp;#39;s in a cage and you still have phobia you know I have have to fear now your fear is not justified you have to stay there and expose right so you teach them to differentiate especially with children you need to have to be very concrete and does that influence the fight-or-flight response what does this why Reese when you when you teach them to freeze does that influence their fight-or-flight responses okay so freeze itself I don&amp;#39;t think it influences the the it influences the reactivity right so they stop themselves from reacting fight and flight response you know as far as understand a sympathetic nervous system we have a lot of skills that are - are getting you know getting the parasympathetic nervous system to get activated what is this you know sympathetic is our fight-or-flight parasympathetic is the one in which you actually you know rest and digest there are lots of skill that we&amp;#39;re teaching them that will activate parasympathetic nervous system meaning that they arousal will come down and they&amp;#39;ll be able to think straight ER and be able to arrive at a solution as opposed to when they&amp;#39;re discombobulated so I&amp;#39;m not sure if I answer that one thank you no I I think that&amp;#39;s helpful we have a couple of questions related to motivation and and getting kids to commit without eliciting defensiveness or them being resistant oh oh great great great okay so Marsha Linehan originally was telling everybody that everybody has to do you know be the other lessons whatever it is everybody has to do the skills that she&amp;#39;s doing that she presented in the way that she is doing them the teacher knows can be different and then she turned and said Francesca that doesn&amp;#39;t apply to you because she understands we&amp;#39;re talking with kit we&amp;#39;re talking about kids here and again I forgot about the question it was about dealing with resistance that might arise when you introduce yeah I don&amp;#39;t know why I got Marsha went in and there okay so and okay I lost my train of thought resistance the motivation oh and the other thing that she told me that everybody has to commit in DBT except for what I do because some kids coming in that you know kicking and screaming don&amp;#39;t want to be there in rally but they do we don&amp;#39;t elicit commitment from kids if we see that the child is not going to make we just we just forget about it we need the commitment from the parent okay all right how young an age do you suggest ignoring the behavior thinking of babies infants as long as it&amp;#39;s not a safety issue how young would you ignore as to not reinforce oh I ignore my all the time from very very is as soon as as soon as they were able to focus on me which probably will be different for one Arietta what would actually suggest but really with my kids especially with my son you know something is going on he&amp;#39;s discombobulated he&amp;#39;s running he&amp;#39;s like he knows the drill okay mom come great job coming down get what happened all right now he&amp;#39;s able to understand and connect you know I need to become my mom is long even going to give me attention if I&amp;#39;m upset so as early as as I don&amp;#39;t know one and a half I guess yeah again just not know research support can you please explain the difference between acceptance versus overindulgence when responding to temper tantrums Oh acceptance does not mean no change acceptance means that I&amp;#39;m accepting that my child is having a tantrum times 10 to temper tantrum however I am in no way going to give it attention that&amp;#39;s the change so there is absolutely no indulgence in terms of the temper tantrum there is a flexibility and built-in if child is crying because you know somebody didn&amp;#39;t look at him right you know that&amp;#39;s one thing you ignore that if child fell and scraped his knee and crying yes absolutely going to come there in a tenth there is you know which parent have to differentiate between is this something that&amp;#39;s temper outbursts is or my child in the real danger or my child actually needs my support has nothing to do with attention seeking we have never questions about the diagnosis I think and his questions about is this also apply to kids who have more internalized instead of having temper tantrums how do you what about childhood bipolar how you tell the difference between that okay right so no in order for a child to be diagnosed with dmdd you know there&amp;#39;s no in there&amp;#39;s some internalizing but you know in terms of some of the feelings that they&amp;#39;re having kind of suppressing some of the things but it&amp;#39;s more of externalizing you know the behaviors that they have because this behaviors come from them not being able to regulate themselves so no it&amp;#39;s not internalizing kids now in terms of difference between dmdd and bipolar disorder so in the night is there was this push to actually classify children that are now called dmdd as bipolar however people were able to recognize that this is a constant chronic thing the the eruptions it&amp;#39;s not something that&amp;#39;s intermittent that would be actually characteristic of a bipolar and would you speak to applying what you DBT for children to children who maybe don&amp;#39;t have the tantrums but their their internalized they don&amp;#39;t have they have other mood problems right right absolutely well there&amp;#39;s research done right now with Tim in the England what&amp;#39;s his name tip escape from the one who was you know who actually have Tom Lee Tim Lynch thank you Tim Lynch is doing internalizing DBT with internalized yes with adults absolutely right I haven&amp;#39;t personally done it right this is something to look at while let me first see what Tim Lynch was able to do with internalizing and then we&amp;#39;ll figure out what to do with myself well some of them are bipolar some of them deem DD it all depends on is it chronic or is an intermittent well the only well how to say it usually we don&amp;#39;t diagnose children as having a personality disorder where you can&amp;#39;t absolutely diagnose a child with personality disorder unless it&amp;#39;s a social personality so which you cannot until they&amp;#39;re 18 however is it really a personality disorder or a lot of it is a learned behavior in my mind a lot of this is a learned behavior what&amp;#39;s there is my personality just sort of per se this is a disorder of emotional regulation that&amp;#39;s built in this is something that they&amp;#39;re born with yes they may be on the trajectory to develop point line personality sort of given their symptoms however I would not start there perhaps on that same vein there&amp;#39;s a question here speaking to the neuroscience that you refer to and would it make more sense to call this a brain disorder is there possibility that DMD would also become state Tai&amp;#39;s child what what&amp;#39;s what&amp;#39;s not a brain disorder mm-hmm oh really you know one of the research that&amp;#39;s going on right now that I&amp;#39;m really excited about you know it&amp;#39;s not published yet kind of like trickle through the grapevine researchers at Harvard Harvard took several you know I think like 12 whatever volunteers and they have them do mindfulness practices for 20 minutes a day for about 20 day 12 days and they took Emma right before and after what they were able to find mind-boggling number one they were able to find that there is a increase in the gray matter in areas that are tension concentration problem solving memory after 20 minutes of mindfulness for 12 days and but I could predict that what I wasn&amp;#39;t able to predict was that there is shrinking in the area that&amp;#39;s fight and flight syndrome as fight in flight so meaning that this the fight and flight is shrinking the other one is expanding so you&amp;#39;ll be able to regulate more and more effectively so yeah here we go I think this is getting to some of the understanding and reinforcement we have the tantrum is lying on the floor face down what is that and what to do we&amp;#39;re thinking about it three-year-olds it&amp;#39;s exactly the same thing ignore ignore ignore now acceptance validation all that stuff comes up either before temper outbursts when you&amp;#39;re just catching the child may be getting into that emotion mind and you catch him right before and say Johnny I totally get it what just happened oh my gosh I got upset too okay can we now breathe together it&amp;#39;s just calm down and then you cut it right then and there or after the tantrum is over child is the more or less normal mood then you process again starting with validation I told and said what happened you were feeling this because of that now the outcome did you like it no what can we do next time differently and then role-played don&amp;#39;t just leave the child hanging there roleplay roleplay roleplay give actual points rewards whatever it is because you need to have behavioral rehearsal in it but one child is on the floor face down tantrum in there - for God there&amp;#39;s no way you can actually do anything and he&amp;#39;s gonna hear you and understand and process it and actually do something different plus you&amp;#39;re going to give it attention so it&amp;#39;s not effective and actually can reinforce the tantrum thank you so much [Applause] [Music]

Transcript for:Lecture on DBT for Children

Transcript for:
Lecture on DBT for Children