DBT for Children: How it Works, Effectiveness, & Examples

What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is an evidence-based talk therapy that focuses on helping individuals accept their reality while simultaneously working on improving their lives. It was developed by Marsha Linehan while working with women who had borderline personality disorder (BPD) and were suicidal.¹ DBT comprises four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Can DBT be Used With Children?

DBT can be used as a treatment for kids ages 6-12 years old. In this regard, the proper term used is DBT for children or DBT-C. If you describe your child as being “highly sensitive” and that they get emotionally overwhelmed by small things to the point where they become physically and verbally aggressive, DBT-C is worth considering.

Remember that dialectical behavior therapy for children does not change a child’s personality but rather their behaviors. The result is that a child learns to calm themselves down and feel less stressed. In DBT-C, parents and caregivers also learn all the skills that will be taught to their kids so that they can reinforce these skills at home.²

How Is DBT Adapted for Children?

Dialectical behavior therapy for kids differs from DBT for adults because kids have unique developmental considerations. A therapist would need to adjust their approach, allowing children to understand DBT concepts and put them into action through play and other creative techniques. Moreover, parents and caregivers are involved in the process so they can support the child.

Ways that DBT is adapted for children include:

• Increased focus on emotional regulation: What makes DBT therapy for children unique is that it emphasizes control over one’s emotional state. Emotional regulation isn’t something children are born with, and some kids have a more challenging time with it.
• Involvement of the caregiver: Your involvement as the child’s parent or caregiver is essential for encouraging them to practice DBT skills at home. For example, whenever they’re feeling, you can instruct or remind them to do a calming activity like hugging their stuffed animal or doing the opposite action of their feeling.
• Shorter session: Compared to adults, DBT-C sessions are shorter to accommodate a child’s shorter attention span. A session would likely range from 45 minutes to an hour, but this also depends on their age and the challenges they’re facing.
• Using simpler language: When explaining DBT, a therapist avoids complex terms the child finds difficult to comprehend. Instead, the therapist uses relatable examples, which can sometimes be drawn from the child’s background or interests (based on their assessment of the child).
• Age-appropriate materials: This includes feelings charts or cards with facial expressions, storybooks, workbooks, board games, cartoon clips, and stress balls.
• Parent training: Parents undergo training sessions to learn the basic concepts of DBT-C. It also includes skills training, which allows them to reinforce DBT skills for kids in real-life situations.
• Family therapy sessions: Kids, parents, and other family members learn problem-solving skills together. Family therapy is an opportunity to explore obstacles that may be causing the child to feel anxious or worsening symptoms of their condition (examples are ADHD and bipolar disorder).

DBT Skills Applied to Children

For DBT-C, the four modules of mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness remain the same but are adjusted to be age and developmentally appropriate. This includes using kid-friendly materials, such as cartoon clips, board games, and colorful handouts. Furthermore, a therapist will replace complex terminology with simpler ones and provide concrete examples to explain concepts.

Here is how the DBT skills are used to treat children:

Mindfulness Skills

Mindfulness in DBT refers to a set of skills that helps kids focus on the present moment. These skills emphasize awareness and acceptance of one’s experiences.³ Having an increased sense of awareness will help in preventing self-criticism. To increase mindfulness, a therapist introduces age-appropriate exercises that children can practice regularly to build the habit.

An example of a DBT mindfulness skill taught to children “Wise Mind Breathing”, which involves breathing in while thinking “Wise”, and breathing out while thinking “Mind.”⁴ It is a form of mindful breathing that helps a child to regulate and settle into Wise Mind. Another simple skill is mindful coloring where kids use coloring materials like crayons, coloring books, and markers to reduce their stress. Kids can also watch and count clouds in the sky, which is an opportunity to practice being in the present moment.

Distress Tolerance Skills

Distress tolerance in DBT is about living through difficult circumstances or situations without engaging in harmful behaviors. Kids who increase their distress tolerance can soothe themselves through relaxing, self-care activities. These activities usually involve using their senses — vision, hearing, taste, smell, touch, and movement.

An example of a DBT distress tolerance skill taught to children is TIPP. TIPP stands for Temperature (putting their face in cold water or taking a cold shower), Intense exercise (such as running, jumping, or playing basketball until they’re tired), Paced breathing (meaning they take slow and deep breaths), and Progressive muscle relaxation (tensing and relaxing the muscles of their body).

Emotion Regulation Skills

Emotional regulation in DBT helps children understand their emotions, which is the first step towards reducing emotional suffering. While different factors — such as age, temperament, environment, and previous experiences — influence a child’s ability to control and express their feelings healthily, adults have a role in helping them do this as well.⁵ In that regard, parents are are also taught the same skills their children learn so they can incorporate and reinforce these skills at home.

Examples of emotion regulation skills that are taught to children include naming their emotions using a feelings thermometer, doing the opposite of what they feel (the “Opposite Action” skill), and caring for themselves using the PLEASE skill (treat Physical iLlness, balanced Eating, avoid mood Altering substances, balanced Sleep, and Exercise).

Interpersonal Effectiveness Skills

Interpersonal effectiveness in DBT helps children build and keep positive relationships with others. This is done by practicing assertiveness, empathy, and validating their feelings as well as others’.⁶ The result is that children gain the tools they need to resolve conflicts healthily. For kids who face peer pressure, developing assertiveness empowers them to resist it, allowing them to make more responsible decisions.

An example of a DBT interpersonal effectiveness skill taught to children is DEARMAN. This acronym stands for “Describe the situation, Express your feelings, Assert yourself, Reinforce the other person if they respond well, Mindful, Appear confident, and Negotiate.” Another skill that children are taught is GIVE, which means being Gentle, acting Interested, Validating others’ emotions, and keeping an Easy manner.

Which Mental Health Disorders Is DBT Used to Treat in Children?

DBT for kids is particularly effective for conditions that involve emotional dysregulation, which then affects their behaviors and interpersonal relationships. Using DBT will help stabilize their emotions as children learn practical skills to handle them in less disruptive ways. In some cases, a therapist may use DBT with other approaches like cognitive behavioral therapy (CBT) for children and medication.

DBT is used to treat the following mental health disorders in children:

• Anxiety: Whether a child is dealing with separation anxiety, social anxiety, or specific phobias, anxiety makes them worry a lot and easily irritated. DBT helps them become aware of their anxious thoughts, which allows them to reduce their intensity.
• Obsessive-compulsive disorder (OCD): Whereas CBT is considered to be the first-line treatment for pediatric OCD, incorporating DBT is also beneficial due to its mindfulness component, which reduces the intensity of obsessive thoughts.
• Attention-deficit/hyperactivity disorder (ADHD): Kids with ADHD get easily frustrated by small everyday annoyances and act too quickly without thinking. Emotional regulation techniques in DBT, such as deep breathing and counting to 10, can help these kids ground themselves.
• Disruptive mood dysregulation disorder (DMDD): DMDD is characterized by severe temper outbursts and chronic irritability. DBT-C teaches kids to handle their feelings and respond calmly to others without lashing out.
• Depression: Depression in children can occur along with other conditions that DBT-C helps address, such as OCD and ADHD. Research shows that distress tolerance, a DBT skill, leads to lower levels of depressive symptoms and helps emotions become more bearable or acceptable.⁷
• Post-traumatic stress disorder (PTSD): Research finds that kids with PTSD struggle with more emotional regulation problems than those without PTSD.⁸ A therapist helps a child identify triggers of traumatic memories and more importantly, develop a plan that helps them feel calm again.
• Autism: Given that autistic kids have unique learning abilities — for example, one child learns best through picture books, whereas the other loves listening — a therapist needs to tailor their approach in a way that aligns with the child’s preferences.

Is DBT Effective for Children?

DBT may have been originally created for adults, but many professionals and families have found it helpful for children and teens who struggle with their mood. However, note that research is lacking for DBT kids compared to adolescents. This is because DBT is primarily used for conditions affecting adolescents and adults.

One research article in Child and Adolescent Mental Health notes that DBT for adults and teens can also hold promise for children demonstrating self-harm and suicidal behaviors. Eleven children who displayed depression, anxiety, and suicide ideation received DBT group skills training twice a week for 6 weeks. All parents considered the program to be helpful for their kids, who also experienced improvements in their symptoms and coping skills.²

DBT Vs. CBT for Children

When comparing CBT and DBT, CBT has much more research that backs its effectiveness in treating mental health disorders in children.⁹ This does not mean that CBT is always the better option, but research on the effectiveness of DBT for children is still developing. The conditions that DBT helps with, such as anxiety, depression, trauma, ADHD, OCD, and DMDD can also be addressed by CBT.

However, the main difference between CBT and DBT is that while CBT focuses on replacing negative thoughts with positive ones, DBT emphasizes accepting negative thoughts and managing the emotions caused by these thoughts. Like DBT, CBT techniques are adjusted according to a child’s language and learning needs. Whereas DBT can be adapted for middle schoolers (ages 6-12 years), CBT can be used for preschoolers (ages 3-5 years) as long as it’s modified.¹⁰

What to Expect During DBT Treatment for a Child

DBT for kids begins with a qualified mental health professional assessing the child to determine if it is the right approach for them. Parents and caregivers receive orientation about DBT, learn the coping skills their kids learn, and acquire parenting techniques to create an environment that encourages positive change.

As for the duration and timeline, DBT-C usually entails weekly sessions that may last 45-60 minutes. The number of weeks will vary depending on the severity of the child’s condition. In some cases, a DBT program may end in less than 24 weeks.

DBT sessions for a child will involve:

• Individual sessions with the therapist: The child learns important skills for mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.
• Tolerance of problematic behaviors during a session: The child may not always be fully engaged in a DBT session by misbehaving or acting on their emotions. In these situations, a therapist simply ignores the behaviors while refocusing the child’s attention.
• Take-home assignments: This includes printable worksheets and handouts, which the child can answer at home and review to practice DBT skills with the guidance of their parents.
• Progress tracking: It’s important for parents and caregivers to observe the child’s use of DBT skills and changes in their mood and behaviors. They can then report these changes regularly to the child’s therapist, who may adjust the plan as needed.

How to Find a DBT Therapist for Your Child

For those interested in exploring DBT as a treatment for their child, it is important to find a therapist who specializes in children and has undergone intensive DBT training. Look for someone with a non-judgmental attitude, an approachable presence, and the ability to communicate with young clients. You can ask your child’s pediatrician for recommendations or use an online therapist directory to find a therapist in your area. If you are struggling to find a DBT-C therapist locally, you may want to explore online therapy options, making this type of therapy easily accessible.

When to Seek Professional Support

It may be time to consider DBT-C for your child if they consistently display intense emotions and impulsivity. For example, they cannot control themselves from saying or doing things that hurt themselves and others. Watch out for signs, such as getting into trouble at school, violent behavior, verbal outbursts, and thoughts of self-harm.

In My Experience

I have used DBT skills as an adjunct to therapy to help my clients cope better with distressing situations that happen in their school, as well as within their peer groups and family. In addition to the four core DBT concepts discussed in this article, I try to introduce the “Walking the Middle Path” concept to help a child understand that not everything is black and white, helping them learn to go outside their own viewpoint.

While I haven’t performed an actual DBT treatment program, I would highly recommend a full fidelity or comprehensive DBT treatment, which has the backing of research. There are many child therapists who provide DBT skills training, but not full fidelity DBT treatment — which would include individual and group sessions, parent involvement, and phone coaching (done between therapy sessions).

However, for families and parents interested in having their kids learn individual DBT skills, know that these skills can still be beneficial as long as they’re provided by a trained therapist.