Integrating Dialectical Behavior Therapy Skills and Parent Training for Dually Dysregulated Parents and Children: An Idiographic Case Study

Abstract

Despite high rates of co-occurrence of psychopathology among parents and children, few interventions simultaneously address clinically elevated symptoms in parent and child as well as parenting. Emotion dysregulation (ED) is a promising transdiagnostic target for such dual-generation interventions. Dialectical Behavior Therapy (DBT) Skills target ED, and there is growing interest in integrating DBT Skills with Parent Training (PT) to improve the mental health of parents and children. In this case study, a 24-week DBT Skills + PT intervention for emotionally dysregulated parent-preschooler dyads was delivered to three parents. We evaluated the process of change in parental ED, parent-reported child ED, and parenting using idiographic statistical analyses of weekly repeated measures (26 timepoints). Feasibility and acceptability of the intervention were also assessed. Results from person-specific linear regression analyses showed large improvements over the course of treatment, and the temporal cascade of changes in parent ED, child ED and parenting varied, suggesting a different process of change for each parent. Feasibility and acceptability were high and parents’ feedback during exit interviews are used to extend the interpretation of the quantitative results. DBT Skills + PT may be a promising transdiagnostic approach to address the needs of parent-child dyads with ED.

The rate of co-occurrence of mental health disorders in parents and their children is high (McLaughlin et al., 2012; National Research Council, Institute of Medicine, 2009; Nicholson et al., 2002; Vidair et al., 2011), with prevalence rate estimates ranging between 18–68% (Middeldorp et al., 2016). While several pathways explain this co-occurrence (Zalewski et al., 2017), parenting is one key mechanism (Patterson & Fisher, 2002). Despite strong evidence linking parent mental health symptoms, parenting practices and behaviors, and child mental health symptoms, there remains a lack of effective treatment options for families in which both parents and their children experience psychopathology (Everett et al., 2021). There is increasing interest in dual-generation approaches that integrate adult mental health and parenting interventions in order to improve symptoms in both parents and their children (Hoagwood et al., 2020; Shonkoff & Fisher, 2013). Integrating Dialectical Behavior Therapy (DBT) Skills and Parent Training (PT) is a promising treatment development direction (Zalewski et al., 2020) because DBT Skills target emotion dysregulation, a transdiagnostic feature of psychopathology, which is linked to parenting and children’s outcomes (Hajal & Paley, 2020). Further, DBT Skills and PT share a behavioral theoretical approach and a group-based, didactic format that lend themselves well to integrating these two evidence-based interventions. The present case study focuses on the development and preliminary testing of a 24-week integrated DBT Skills + Parent Training (DBT Skills + PT) program for emotionally dysregulated parent-child dyads. It is unique in both the intervention itself (e.g., the integration of DBT and parenting skills), as well as in its methodological design, which included idiographic analyses of weekly changes in three interlinked domains: parental emotion dysregulation, parenting practices, and child emotion dysregulation. DBT Skills + PT may be one way to address dual-generation mental health.

Parental psychopathology is an established risk factor for the development of child mental health problems (McLaughlin et al., 2012), and bidirectional effects point to the negative impact of children’s mental health symptoms on parents’ mental health (Gross et al., 2008; Pardini, 2008; Sellers et al., 2016). Parenting behavior is a key modifiable mechanism of the intergenerational transmission of psychopathology in which less effective parenting behaviors are linked to the development of child mental health disorders (Chronis-Tuscano et al., 2016; Goodman & Gotlib, 1999). Furthermore, bidirectional associations suggest children with behavior problems may evoke poorer parenting (Fite et al., 2006; Patterson & Fisher, 2002). Despite these known links between parent mental health disorders, poorer parenting, and child mental health disorders, predominant treatment approaches only target and assess symptom reduction at the individual level for parents or children. Among the few examples of adult mental health treatments provided to parents that also assessed downstream effects on their children’s symptoms, the effects reported were minimal. Specifically, a small meta-analysis (n = 7) found that treatment of maternal depression was linked to downstream improvements in child mental health, with a small effect size (Cuijpers et al., 2014). Among parenting interventions that target parenting behavior, there is mixed support regarding the extent to which parents’ symptoms are improved (Barlow et al., 2012; Furlong et al., 2012; Leijten et al., 2018).

Increasingly, there are calls for the development of more dual-generation treatment approaches (Goodman & Garber, 2017; Shonkoff & Fisher, 2013). One type of dual-generation approach is to intervene on families in which a parent has a mental health disorder, with the dual purpose being to both target parent mental health symptoms and prevent symptoms from developing in their children. However, these interventions are not designed to treat existing child symptoms (Compas et al., 2009; Ginsburg et al., 2015). A second type of dual-generation treatment is designed for parents and children who are both experiencing current mental health symptoms. However, few of these exist and much of treatment development in this area has focused on addressing maternal depression and children’s externalizing disorders (Chronis-Tuscano et al., 2013; Verduyn et al., 2003). Promising results from treatments that do target both parent mental health and parenting highlight the potential of transdiagnostic integrated interventions to improve symptoms in both parents and their children (Everett et al., 2021).

Emotion dysregulation (ED), a transdiagnostic feature of adult psychopathology (Sloan et al., 2017), is particularly important in the parenting context because it undermines a parent’s ability to model effective emotion regulation techniques to their children (Eisenberg et al., 1998; Hajal & Paley, 2020; Morris et al., 2007), to engage in effective parenting (e.g., parent management behaviors), and/or to respond effectively when a child is emotional (i.e., parental emotion coaching; Rutherford et al., 2015). DBT, originally developed for the treatment of borderline personality disorder, is a broadly disseminated transdiagnostic treatment approach that targets emotion dysregulation and is applicable to a wide range of mental health disorders (Ritschel et al., 2015). Given DBT’s effectiveness at improving emotion regulation, and the growing understanding around the importance of parental emotion regulation to parenting and children’s outcomes (Hajal & Paley, 2020), there is increasing interest in the novel application of DBT to parents with psychopathology, as a means towards reducing the transmission of emotion dysregulation to children (Zalewski et al., 2018). DBT Skills training, a group-based component of the full DBT model, is increasingly acceptable as a stand-alone treatment for certain disorders (Linehan et al., 2015; Valentine et al., 2015). DBT Skills is an optimal treatment choice for integration with parenting interventions, as it shares both a behavioral theoretical approach and a group-based, didactic format with parent training interventions. There is increasing recognition that integrating DBT Skills and parenting may be a promising transdiagnostic dual-generation treatment approach (Zalewski et al., 2020). Below, we briefly overview the work done to date integrating DBT Skills with child and parenting interventions.

DBT Skills With Adult-Focused vs Child/Adolescent-Focused Integrations

Case studies and pilot studies of adult-focused treatment approaches have examined how adults receiving DBT Skills might apply them to parenting contexts (Ben-Porath, 2010; Martin et al., 2017; Woods-Jaeger et al., 2018). Martin and colleagues’ (2017) case study of a DBT Skills group for mothers with severe emotion dysregulation found that nearly half of the mothers’ weekly DBT Skills use was in a parenting context, pointing to the potential benefit of using DBT Skills towards improving parenting. Some DBT treatments that target children and adolescents (DBT-C: Perepletchikova et al., 2017; DBT-A: McCauley et al., 2018; Mehlum et al., 2014) have approached integration of DBT Skills and parenting by providing parents with parenting skills and/or DBT Skills, in addition to providing the child and adolescent-focused intervention. Results from randomized controlled trials show reductions in children’s mood symptoms and adolescents’ self-harm behaviors and suicidal ideation (McCauley et al., 2018; Mehlum et al., 2014; Perepletchikova et al., 2017); however, parenting and parent mental health outcomes were not reported. Berk et al. (2020) tested an 8- to 10-session parent-only DBT Skills-based parenting intervention for parents of self-harming youth. The intervention emphasized DBT Skills components in treatment that include principles of parent management training such as contingency management (e.g., reinforcement, punishment). Results from the feasibility pilot study (n = 10) pointed to decreases in parents’ depressive symptoms and emotion dysregulation, as well as reductions in adolescents’ self-harm, with no significant changes in parenting practices.

DBT Skills Emphasis vs Parent Training Skills Emphasis

The efforts reviewed above to integrate DBT Skills and parenting have emphasized provision of DBT Skills over parenting skills (e.g., devoted more sessions to DBT). Other integrations have emphasized the parent training components within treatment. For example, Katz et al.’s (2020) 12-session parental emotion coaching intervention for survivors of intimate partner violence included only two sessions devoted to DBT Skills. Results from the pilot study point to post-intervention improvements in maternal emotion regulation and parenting practices and behaviors, as well as reductions in children’s depressive symptoms and negative behavior. It is notable that the program focused on parental emotion coaching, as parents who struggle with their own emotion dysregulation have been found to engage in less supportive emotion coaching and more invalidating parenting behaviors when responding to their children’s negative emotions (Lee et al., 2023), and may benefit from parenting programs specifically aimed at enhancing emotion coaching behaviors (Chronis-Tuscano et al., 2016; Havighurst & Kehoe, 2017).

Other treatment development efforts in this area have devoted sessions to DBT Skills and parenting skills more equally (Renneberg & Rosenbach, 2016; Roos et al., 2021). In addition to receiving DBT Skills focused on enhancing mindfulness, distress tolerance and emotion regulation, mothers with borderline personality disorder in Renneberg and Rosenbach’s (2016) 12-session intervention were also provided skills related to the basic needs of children, establishing a balance of structure and flexibility in parenting, understanding children’s emotions, and identifying helpful and unhelpful beliefs about parenting. The study did not evaluate post-intervention changes in quantitative parent and child outcomes, but mothers did provide overall positive qualitative feedback on the acceptability of the intervention. Roos and colleagues’ (2021) 20-session BRIDGE program is a novel parenting intervention developed for depressed mothers of preschoolers that paired specific DBT Skills with parenting skills in each session. Results showed posttreatment reductions in maternal depressive symptoms and emotion dysregulation, reductions in harsh and dismissive parenting behaviors, as well as reductions in children’s behavior problems. An interesting exploratory finding showed that reductions in children’s behavior problems were associated with the improvements in maternal depression, providing some evidence of the link between intervention related changes in parent mental health and children’s mental health (Roos et al., 2021).

Idiographic Approaches to Identifying Mechanisms of Change

Most of the studies reviewed above lack the repeated measures necessary for an examination of longitudinal trajectories of change throughout the intervention. Repeated measures permit the evaluation of potential mechanisms of change by affording the observation of the cascading order of changes among parent mental health, parenting, and child mental health, and how change in each domain impacts the other domains. Additionally, all previous DBT + parenting integrations have relied on nomothetic approaches to analyze group-level changes. Evaluating group-level changes has potential benefits of enhancing generalizability and replicability of treatment results. However, this is not always the case, as group-level inferences do not always generalize to the individuals within a group (Fisher et al., 2018). Idiographic, personalized approaches to treatment development, with repeated measures to evaluate change at the individual level, are increasingly used to understand mechanisms of change within treatments (Boswell & Bugatti, 2016; Boswell & Schwartzman, 2018; Fernandez et al., 2017; Fisher et al., 2019; Hoenders et al., 2012). Idiographic approaches lend themselves well to evaluating response trajectories during treatment and offering insight on potential mechanisms driving treatment-related changes (Barlow & Nock, 2009; Brown et al., 2019; Wright & Woods, 2020). This type of analysis is particularly important to informing the emerging treatment development work around DBT Skills + parenting interventions, which all share the aim of improving multiple domains in both parents and children. Moreover, idiographic approaches, which are often more flexible, efficient, and require less resources than larger-scale group comparison designs (e.g., RCTs), are also well suited to the early stages of treatment development in which DBT + parenting interventions are currently positioned (Rizvi & Nock, 2008).

The Current Study

We pilot tested a 24-week DBT Skills + parent training (DBT Skills + PT) group intervention for dually dysregulated parent-preschooler dyads. Recognizing the unique needs of families in which both parents and children are experiencing emotion dysregulation, the intervention equally emphasized DBT and parenting skills, and provided both parent management training skills and parental emotion coaching skills. We sought to combine two well-established manuals that are already widely available and disseminated, and to pair the DBT and parenting skills in a conceptually coherent way.

The intervention was conducted with three parents with elevated levels of ED who also reported that their preschool-aged child was exhibiting elevated levels of behavior or emotional problems. The aim of the intervention was to improve the following three domains: parental emotion dysregulation, parenting practices, and children’s behavioral and emotional problems. Our study had two primary objectives. First, using idiographic methods, we aimed to examine week to week patterns of change at the dyadic level in each of the three domains from baseline, throughout the 24 weeks of treatment, and at follow-up. Aim 1 was to describe individual-level patterns of change in parental ED, parenting practices, and child ED over the course of treatment. We hypothesized that parents would report improvements in each of these three domains, with large linear effects. Moreover, we hypothesized there would be cascading effects between parental ED, parenting practices, and children’s ED such that reductions in parental ED would precede improvements in parenting, which, in turn, would predict reductions in child ED. However, we also anticipated that these patterns may differ across parent-child dyads and that the idiographic approach may help generate other hypotheses with regards to mechanisms of change. Our second aim was to assess the feasibility, acceptability, and implementation of the intervention by evaluating client attendance and attrition rates (feasibility), quantitative and qualitative feedback from participating parents (acceptability), and parents’ DBT and parenting skill use (implementation). We anticipated high feasibility and acceptability of the DBT Skills + PT intervention, and levels of skill implementation that are comparable to previous DBT and parent training trials.

Methods

Procedures

The study was conducted at a university in the Pacific Northwest of the United States and recruitment began in January of 2020. All data collection was completed by March 2021. While initial clinical intakes to establish eligibility were conducted in-person, due to Covid-19 pandemic-related restrictions on in-person meetings that were put in place in March of 2020, the study transitioned into a telehealth format and all group sessions were conducted via a HIPAA-compliant teleconferencing platform (i.e., Zoom) and all data collection was conducted via online questionnaires (i.e., Qualtrics). Telehealth-delivered Zoom sessions began in August 2020 and continued through February 2021.

Parents were recruited via a university department-maintained database that tracks families interested in participating in research and via online posts (e.g., Craigslist). Parents responding to recruitment materials completed an online screening survey to assess initial eligibility criteria. This included parents endorsing a score of >88 on the Difficulties with Emotion Regulation Scale (DERS), which is equivalent to +.5 standard deviation above a community norm (Ritschel et al., 2015). Additionally, parents had to report that their 3- to 6-year-old child met a cutoff for emotional and/or behavioral difficulties on the Strengths and Difficulties Questionnaire (SDQ; Total Difficulties Score >15 or Emotion Problems Score >3 or Conduct Problems Score >3). These scores were selected to reflect “slightly raised” to “high” levels of difficulties in the SDQ’s 4-band categorization system. Eligibility criteria also required parents confirm that they were 18+ years of age, that they had at least partial custody of a 3- to 6-year-old child that had no known developmental disability, and that they were proficient in English (the language in which the group therapy was conducted). Finally, following the transition to telehealth sessions, parents also had to be able to access Zoom in order to participate. In all, 30 parents completed the online screening survey and 8 of them met the initial eligibility criteria. Four of these parents either did not respond to further contact by the project coordinator or chose not to participate in a clinical intake. Four parents were reached and participated in a clinical intake, which included the Structured Clinical Interview for DSM-5 (SCID-5), conducted by a master’s-level clinician, in order to determine eligibility for the full study. During the clinical intake, parents were excluded if they had an IQ score of <70 on the Peabody Picture Vocabulary Test (PPVT-IV); were psychotic as determined by the SCID-5; or were suicidal with an active plan. All 4 parents who participated in the clinical intake met eligibility criteria for the full study. However, following the study’s transition to a telehealth format due to Covid-19 restrictions, 1 parent dropped out prior to the baseline assessment. Thus, 3 parents participated in the study. These 3 participating parents completed two pre-intervention surveys, which were obtained 1 week before and then immediately prior to treatment initiation, to establish their baseline scores.

The intervention period consisted of 24 weekly sessions, with weekly self-report measures taken approximately 24 hours before each group session. The follow-up assessment was completed 1 week after group therapy ended, when parents completed an online survey. One to 2 weeks later, parents also completed a 30-minute exit interview about their experience in the DBT Skills + PT group therapy. Exit interviews were conducted by a master’s-level clinician who was not one of the group therapists.

Baseline, weekly, and follow-up surveys included a battery of self-report measures of parent ED and parenting practices, parent-report measures of child emotion dysregulation, and self-reported DBT and parenting skill use. All survey data was collected online via Qualtrics and parents were compensated for each phase of the study (clinical intake, baseline surveys, weekly surveys, follow-up survey, and exit interview), earning up to $360 for their participation in all phases. All study procedures were IRB approved and the study protocol was registered on clinicaltrials.gov (NCT04740138). All participants consented at intake and then were reconsented with the revised study protocol and additional telehealth guidelines put in place due to Covid-19 restrictions. Participants consented to their data being presented in the deidentified, nonaggregated, individual-level format in which study results are reported here.

Participants

The three participating parents were two female mothers (Parents A and C) and one male father (Parent B). Parent ages ranged between 35–47 years old. Each of the three parents had two children in their household, but reported on only one child who met criteria for the study. Their children’s ages ranged between 3–6 years old per eligibility criteria. All three parents identified as heterosexual and married. Two of the three self-identified as White and the third did not report their racial identity. Level of education ranged between a bachelor’s degree and a doctorate. Family’s annual income ranged from $50,000 to over $100,000. Parent A reported a lifetime diagnosis of bipolar disorder, which was confirmed during the intake assessment. This was the only current mental health diagnosis they met criteria for on the SCID 5 at intake. Parents B and C did not meet criteria for a current mental health disorder on the SCID 5.

At the time of initial eligibility screening, parents reported high levels of difficulties with emotion regulation on the DERS, with their scores ranging from 90 (approximately +.6 SD above a normative score) to 121 (approximately +2SD above a normative score). Parents also reported high levels of child emotional and behavioral difficulties on the SDQ, with Total Difficulties scores ranging from 17 to 23. Following the delayed start of the intervention due to the Covid-19 pandemic, when baseline assessments were conducted approximately 5 months after intake, parents’ scores on the DERS and SDQ had decreased. Parent A still reported elevated levels of ED on the DERS and child emotional and behavioral difficulties on the SDQ, while parents B and C reported normative levels of their own ED and their child’s emotional and behavioral difficulties.

Intervention

The DBT Skills + PT group intervention integrated DBT Skills, Parent Management Training, and Emotion Coaching. Prior to beginning the group sessions, each of the participating parents met individually with the lead DBT Skills therapist for a single 1-hour orientation session. The orientation session was aimed at building an initial therapeutic alliance, orienting to group rules, and identifying individual therapy goals using a DBT Skills handout on the Goals of Skills Training. In addition to goals related to their own mental health, participants were also encouraged to identify goals related to their parenting. Each weekly group session was approximately 2.5 hours in length. The structure of each group session included a brief mindfulness practice (~10–15 minutes), homework review to discuss use of skills previously learned (~50 minutes), a break (~10–15 minutes), didactics to learn a new set of DBT and/or PT skills (~60 minutes), and assignment of homework (~10 minutes). Session topics are presented in Table 1. Role-played video clips (see Supplementary video files 1–4) illustrate some of the ways DBT and parenting skills were integrated: a homework review clip on the use of mindfulness in parenting contexts, a didactic clip on the DBT opposite action skill in the context of labeling and validating children’s emotions, an in-session group discussion on identifying when to use DBT crisis survival skills in parenting situations, and an exercise using the DBT pros and cons skill to examine a common parenting challenge of resisting the urge to yell in parenting situations.

Table 1.

Session Plan, Including Skills Taught and Page Numbers of Handouts Referenced From the DBT Skills and Parent Training Manuals

Session #	DBT Module	DBT Skills	DBT Skills Handouts Referenced (Linehan, 2015b)	Parenting Skills	Parenting Skills Handouts Referenced (Harvey et al., 2015)
1	Mindfulness	Wise Mind: States of Mind	Pgs. 45–52, 83
2	Mindfulness	What and How Skills	53–63, 84, 88
3	Distress Tolerance	Crisis Survival Skills: STOP, Pros and Cons	321–328, 375
4	Distress Tolerance	Crisis Survival Skills: TIP, Distracting	329, 333, 376
5	Distress Tolerance	Crisis Survival Skills: Self-soothing, Improve the Moment	334, 336, 379, 382, 386	Learning Principles: Reinforcement and Punishment;Using Praise	Pgs. 170–173
6	Distress Tolerance	Reality Acceptance Skills: Radical Acceptance, Turning the Mind	342–345, 394
7	Distress Tolerance	Reality Acceptance Skills: Willingness, Half-Smiling and Willing Hands	346–349, 397
8	Distress Tolerance	Reality Acceptance Skills: Mindfulness of Current Thoughts	350–352	Using Attention/Ignoring to Shape Children’s Behavior	174–176
9	Mindfulness	Wise Mind: States of Mind	Pgs. 45–52, 83
10	Mindfulness	What and How Skills	Pgs. 53–63, 84, 88
11	Emotion Regulation	Understanding and Labeling Emotions	201–223, 281
12	Emotion Regulation	Checking the Facts	227–228, 285–286	Children’s Emotion Development and Labeling Children’s Emotions; Teaching Children Appropriate Ways to Express Emotions	196–202
13	Emotion Regulation	Opposite Action	230–240, 288
14	Emotion Regulation	Problem Solving	241–244, 289–290
15	Emotion Regulation	Accumulating Positive Emotions: Pleasant Events	247–251, 295	Teaching Children Problem Solving and Negotiating Skills	194–195
16	Emotion Regulation	Accumulating Positive Emotions: Values	252–255, 299
17	Emotion Regulation	B-C PLEASE Skills	256–257, 301, 304	Giving Children Opportunities to Experience Positive Emotions; Scaffolding	215–218
18	Mindfulness	Mindfulness of Current Emotions; Wise Mind: States of Mind	Pgs. 264,45–52, 83	Validating Children’s Emotions	205–207,211–212, 214
19	Mindfulness	What and How Skills	Pgs. 53–63, 84, 88	Reward Systems	180
20	Interpersonal Effectiveness	Understanding Obstacles; Clarifying Goals	117–124, 173
21	Interpersonal Effectiveness	DEAR MAN	125–126
22	Interpersonal Effectiveness	GIVE; FAST	128–130	Using Effective Commands	184–187
23	Interpersonal Effectiveness			Using Logical and Natural Consequences and Rewards	188–190
24	Interpersonal Effectiveness	Evaluating Options; Middle Path: Dialectics	131–133, 150–151

The session schedule was based on the 24-week Standard Adult DBT Skills group schedule (Linehan, 2015a) and DBT Skills portions of each session followed the DBT Skills Training Manual Second Edition (Linehan, 2015a) and DBT Skills Training Handouts and Worksheets Second Edition (Linehan, 2015b). DBT Skills from each of the four DBT modules (Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness) were covered. Parent Training followed the Parenting Hyperactive Preschoolers Clinician Guide (Harvey et al., 2015), which was selected because it is an evidence-based parent training program that integrates both parent management training and emotion coaching (Herbert et al., 2013). The intervention followed the Standard Adult DBT Skills group schedule, and we paired parent training skills with the DBT Skills in a conceptually coherent manner. We adjusted the ordering of parent training skills and integrated them into the session schedule based on the following conceptual guidelines:

1. The first four sessions were solely devoted to DBT Skills, in an effort to allow parents to focus on their own mental health and to give them foundational skills necessary to effectively implement parenting skills presented in later sessions.

2. As is standard in parent training programs, the parenting skills began with a focus on increasing warmth and positive reinforcement and later progressed to focus on limit-setting.

3. When DBT Skills and parenting skills were conceptually similar (e.g., understanding emotions), we first taught the parent the DBT skill to apply on themselves, and then the following week, taught the parent the parenting skill to apply towards their child.

4. We sought to integrate parenting skills into sessions in which the time devoted to DBT Skills was more easily condensed.

Session format was primarily didactic but also included group discussions, in-session exercises, modeling and home exercises that involved practicing the DBT and PT skills. In addition to the 2.5-hour weekly group sessions, the intervention also included 1-hour weekly therapist consultation team meetings, and as-needed phone calls to review missed material and facilitate group attendance. We also conducted individual check-ins with group members during session breaks, including use of the Linehan Risk Assessment Management Protocol (Linehan et al., 2012) to assess for suicide risk, if and when needed.

Interventionists

The DBT Skills co-leaders (one male and one female) were both master’s-level therapists enrolled in a clinical psychology doctoral program. The therapists had each participated in 70 hours of weekly didactic training where they learned the full treatment model and received in-depth training on the second edition of the DBT Skills Training Manual (Linehan, 2015a). Additionally, each had previous clinical experience working with parents and children in the context of evidence-based parenting programs. The therapists received team supervision and participated in a weekly consultation team with their supervisor (last author; a licensed clinical psychologist and DBT expert). Both therapists were parents themselves.

Measures

Parental Emotion Dysregulation

The Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is a 36-item self-report measure used to assess adult emotion dysregulation. Items are rated on a scale of 1 to 5, with higher scores indicating higher levels of emotion dysregulation. The measure is comprised of six subscales: lack of emotional awareness, lack of emotional clarity, limited emotion regulation strategies, difficulties with impulse control, difficulties engaging in goal-directed behavior, and nonacceptance of emotional responses. In this study, the DERS total scores were used for analyses. The DERS was measured at baseline, follow-up, and all weekly timepoints.

Child Emotion Regulation

The Emotion Regulation Checklist (ERC; Shields & Cicchetti, 1997) is a 24-item parent-report measure in which parents rate (on a Likert scale of 1–4) how characteristic of their child are statements which focus on mood lability, lack of flexibility, dysregulated negative emotion, empathy, emotional self-awareness, and positive response to others. The measure produces two subscales (lability/negativity, which provides a measure of emotion dysregulation, and an emotion regulation subscale). The ERC was measured at baseline, follow-up, and all weekly timepoints.

Parental Emotion Socialization Practices

The Coping with Children’s Negative Emotions Scale (CCNES; Fabes et al., 2002) assesses parental emotion socialization practices when responding to children’s negative emotions. Parents are presented with 12 vignettes describing scenarios in which their children exhibit distress. Parents rate (on a Likert scale of 1–7) the likelihood they would engage in 6 potential parental responses to these situations, with each corresponding to 6 subscales: distress reactions, punitive reactions, minimization, expressive encouragement, emotion-focused reactions, and problem-focused reactions. The first three can then be summed into a composite for Invalidating/Unsupportive parenting responses to children’s negative emotions and the latter three can be summed into a composite for Validating/Supportive parenting responses to children’s negative emotions. The CCNES was measured at baseline, follow-up, and all weekly timepoints.

Feasibility

Client attendance was recorded by group leaders and served as a measure of feasibility of the intervention.

Acceptability

The Client Satisfaction Questionnaire (CSQ-8; Attkisson & Zwick, 1982) was used to assess acceptability of the intervention. It is a brief 8-item self-report measure in which clients were asked to rate (on a Likert scale of 1–4) their satisfaction with the intervention. A semistructured qualitative exit interview was conducted post-intervention to evaluate parents’ satisfaction with the intervention, challenges they experienced completing the intervention, their use of DBT + Parent Training skills, and suggestions they had for improving intervention delivery. Representative quotes and themes were gleaned from the interviews.

Implementation of Skills

The DBT Ways of Coping Checklist (DBT-WCCL; Neacsiu et al., 2010) is a 38-item self-report questionnaire that measures the frequency of DBT Skills use and served as a measure of participating parents’ implementation of skills. The DBT-WCCL was measured at baseline, follow-up, and all weekly timepoints.

A Skill Use Diary Card developed for this study was used to assess parents’ weekly use of specific DBT and parenting skills. Parents were asked to mark the days of the week in which they used each skill, and to mark if DBT Skills were used in a parenting or a nonparenting context. The diary card served as an additional measure of participating parents’ implementation of skills. The Skill Use Diary Card was measured at all weekly timepoints.

Analytic Plan

The first aim was to conduct idiographic analyses of week-to-week patterns of change at the level of each individual parent-child dyad. Utilizing advances in idiographic statistical approaches (Brown et al., 2019), time series analyses of repeated measures from the 26 weekly assessments were conducted. These individual-level weekly change patterns were evaluated by examining linear trajectories over time (up to 26 timepoints) for each of the participating parents. Linear regression models were used to test the relationship between time (coded in days, as an independent variable) and each of the outcomes (as dependent variables). In line with recommendations for idiographic analyses in instances with lower power to detect significant effects (Brown et al., 2019), a more conservative approach to interpreting results was taken, focusing on large effect sizes rather than on the significance of p-values. Large linear effects (d ≥ 0.8), in contrast to small or medium effects, were viewed as less likely to be spurious and are the only effects reported. Outcomes for which large linear effects (d ≥ 0.8) were identified were then further examined using exploratory time-lagged analyses to identify potential transactional relationships and cascading effects between parental ED, parenting practices, and child emotion regulation. To conduct these analyses, each weekly outcome variable was lagged by 1 observation (t-1), and then regression models were constructed for each outcome variable as a predictor of a dependent outcome variable at the subsequent timepoint (t), while controlling for the autoregression of the dependent variable (e.g., a regression model with parental ED at (t-1) predicting child ER at (t), while controlling for parental ED at (t)). Significant lagged-effects (p < .05) are reported along with their corresponding effect sizes.

The second aim was to assess the feasibility, acceptability, and implementation of the intervention. Feasibility of the intervention was assessed via attendance and attrition rates. Acceptability was determined by averaging the total scores from the client satisfaction questionnaire (CSQ-8) and by summarizing qualitative data from the qualitative exit interview. Implementation was determined by comparing the average number of DBT and parenting skills parents reported using each week on the diary card to documented ranges of expected skills usage and by examining the effect size of individual-level linear changes in the diary card skill use and DBT-WCCL scores.

Results

Below, we present results from each of these two aims, organized by reviewing each of the three participating parents. Table 2 summarizes results of the person-specific linear regressions for all three parents. Parents A and C completed all 26 weekly assessments. Parent B completed 17 out of 26 weekly assessments (65%).

Table 2.

Results of Person-Specific Linear Regressions for Parents A, B, and C

	Variable	b	p	t	Cohen’s D	df
Parent A
	Parental Emotion Dysregulation (DERS)	−.67	<.001	−4.44	−1.23	24
	Child Emotion Dysregulation (ERC-LN)	−.79	<.001	−6.38	−1.77	24
	Child Emotion Regulation (ERC-ER)	.47	.016	2.58	.72	24
	Supportive Parenting (CCNES)	.61	<.001	3.81	1.06	24
	Invalidating Parenting (CCNES)	−.44	.023	−2.43	−.67	24
Parent B
	Parental Emotion Dysregulation (DERS)	−.14	.606	−.53	−.19	14
	Child Emotion Dysregulation (ERC-LN)	.58 *	.017	2.68	.92	15
	Child Emotion Regulation (ERC-ER)	−.06	.826	−.22	−.08	15
	Supportive Parenting (CCNES)	.54	.036	2.34	.85	13
	Invalidating Parenting (CCNES)	−.46	.084	−1.87	−.68	13
Parent C
	Parental Emotion Dysregulation (DERS)	−.51	.007	−2.93	−.81	24
	Child Emotion Dysregulation (ERC-LN)	−.69	<.001	−4.69	−1.30	24
	Child Emotion Regulation (ERC-ER)	.72	<.001	5.13	1.42	24
	Supportive Parenting (CCNES)	.55	.003	3.25	.90	24
	Invalidating Parenting (CCNES)	.67 *	<.001	4.43	1.23	24

Large linear effects (d ≥ 0.8), which are a more reliable indicator of change, are marked in bold.

^*Direction of change was in contrast to expected results.

Parent A

Over the course of treatment, she showed large decreases in parental emotion dysregulation (d = −1.23) and child emotion dysregulation (d = −1.77), as well as large increases in supportive parenting (d = 1.06). Large effects were not found for changes in child emotion regulation and in invalidating parenting (d = .72 and −.67, respectively). Time lagged analyses of the three outcomes for which large effects were found (parental ED, child ED, and supportive parenting) revealed that for Parent A, increases in supportive parenting significantly predicted subsequent decreases in parental ED, with a moderate effect size (p = .050, d = −.58). Decreases in parental ED (p = .034, d = .64) and increases in supportive parenting (p = .031, d = −.65) each independently predicted subsequent decreases in child emotion dysregulation.

With regards to measures of feasibility, acceptability, and implementation: Parent A attended 22 of the 24 sessions and reported very high satisfaction with the group therapy program (scoring 32 out of 32 on the quantitative CSQ-8 measure). Moreover, in her qualitative feedback, she stated: “This group has literally changed my life and the life of everyone in my family. My mental illness used to run our lives because I was losing control multiple times a day, every day. Now I lose control maybe a couple times a week but the episodes are less intense and last less time… I wish they could give every parent with mental illness something like this. I feel like nobody else is going to get this. I’m so lucky.”

Parent A stated that her motivation for joining the group was “to be a better parent… I have a mood disorder, so it’s hard. This is the first parenting class I’ve taken that addressed anything other than very child related things.” Her observations of changes in herself and her child were consistent with the improvements found in the quantitative results, as she stated: “I have a lot more ability to not flip out. I have more tools in my toolbox. My kids push me all day and I feel like now I’m dealing with it better 70–90% of the time, whereas before I was dealing with it well 10% of the time. So that’s a huge improvement… It definitely showed me the positive feedback loop of when you give [children] positive attention… [it] stops them nagging at you [and the] negative attention cycle.”

She also identified aspects of the program that were most helpful, as well as areas for improvement: “Having a group is helpful. Learning the skills is the most helpful thing. The Distress Tolerance skills were the most useful… It sucked that it was on Zoom [and] it was really long. The Interpersonal Effectiveness skills [were less helpful].”

Parent A’s skill implementation was very high. She showed 100% compliance in completing all 23 weekly diary cards and reported using a daily average of 9.60 (SD = 5.15) DBT Skills in non-parenting contexts, a daily average of 7.77 (SD = 5.48) DBT Skills in parenting contexts, and a daily average of 2.98 (SD = 3.08) parenting skills. This is much higher than previously documented levels of DBT skill use amongst mothers in a Standard Adult DBT Skills group (e.g., 4.56 DBT skills/day in non-parenting contexts and 3.24 DBT skills/day in parenting contexts; Martin et al., 2017). Her use of these skills increased over the course of the group therapy intervention. On the diary card measure, she reported large and significant increases in DBT skill use in nonparenting contexts (p < .001, d = 1.98), in DBT Skill use in parenting contexts (p < .001, d = 1.75), and in parenting skill use (p < .001, d = 1.90). Person-specific linear regressions of the DBT-WCCL measure did not show significant linear change in her DBT Skill use (p = .21), but she did report significant decreases in dysfunctional coping (p = .039) with a medium effect size (d = .60).

Parent B

Parent B showed increases in supportive parenting (d = .85), and contrary to the expected direction of change, he reported increases in his child’s emotion dysregulation (d = .92). No other large effects were found. Time lagged analyses found no significant lagged effects.

In his qualitative exit interview, Parent B stated that his motivation for joining the group was to find out more about DBT and to become a better parent. Consistent with quantitative results, he stated that he had observed “No changes in me personally or in my child” over the course of treatment.

Parent B showed high attendance (22 out of 24 sessions) and reported moderate satisfaction with the group therapy program (15 out of 32 on the CSQ-8). Qualitative feedback from his exit interview provided context for these results: “I don’t know that I gained any skill or knowledge. It was an overview of DBT and that was helpful, but I can’t think of specific things I found valuable. [Participating] was worthwhile. During the pandemic it was an opportunity to connect with other people and that was beneficial. And getting the broad overview of what DBT is was part of it.” He identified the DBT components as being more helpful than the parenting components and also noted areas for improvement: “It would have been better to meet in person. That would have made things better in terms of connecting with other people. Lengthy meetings on zoom are taxing… At home there are interruptions”.

Parent B provided information on his engagement and implementation of skills during the qualitative exit interview: “We’d do whatever in the class and then had ‘quote unquote homework to do’ but for me it didn’t click. Maybe I didn’t put in enough effort to make it click. Maybe it’s from my side.” Consistent with this, he showed moderate compliance with the diary card measure of skill use, completing 15 out of 23 diary cards (65%). In line with previously documented ranges of daily skill use (Martin et al., 2017) he reported using a daily average of 4.53 (SD = 3.46) DBT Skills in nonparenting contexts, a daily average of 4.41 (SD = 3.37) DBT Skills in parenting contexts, and a daily average of 8.65 (SD = 5.70) parenting skills. Person-specific linear regression models of diary card-reported skill use did not reveal any significant changes over time in skill use. Likewise, Parent B showed no significant linear change in DBT Skill use on the DBT-WCCL. However, he did show a significant increase over time on the dysfunctional coping subscale (p = .01) with a large effect size (d = .98).

Parent C

Parent C showed improvements in most outcomes: decreases in parental emotion dysregulation (d = −.81) and child emotion dysregulation (d = −1.30), increases in child emotion regulation (d = 1.42) and in supportive parenting (d = .90). Contrary to expected results, she showed increases in invalidating parenting (d = 1.23).

Results of time-lagged analyses provided partial support for the hypothesized cascade of effects. While parental ED did not have any significant lagged effect on parenting or child outcomes, increases in Parent C’s supportive parenting did predict subsequent decreases in child emotion dysregulation (p < .001, d = −1.13) and increases in child emotion regulation (p = .028, d = .66). No other significant lagged effects were found.

Parent C showed high attendance (21 out of 24 sessions) and rated her satisfaction level as being very high (32 out of a possible 32 on the CSQ-8). In her qualitative feedback she provided more details on her motivation for joining the group and on her high satisfaction with the program: “This [group therapy] seemed like a good opportunity to focus on parenting my children and getting support with that. I liked focusing on the curriculum, having a workbook, and homework (even though I didn’t always do it) and activities, so it wasn’t just a support group. It was focused on learning and practicing the skills. I liked the group members a lot and how we could problem solve actual issues people were having day to day with parenting and other aspects of life. I thought it was really good. It was really helpful that the facilitators were parents so they could really relate to everything. They shared their own examples of situations.”

In discussing the more helpful aspects of the group therapy she stated: “Practicing the mindfulness skills is really helpful. Getting centered before acting. Being really open about your feelings and encouraging children to be open about their feelings. Doing opposite action and remembering your goal. There were many useful skills.” She also noted the following areas for improvement: “It’s hard to have that much alone time, especially when kids aren’t in school. Connecting over zoom [was challenging]. Each session was long and the number of sessions was long…The mindfulness stuff and the parenting part was really good. At the end we started talking about relationships and how to have difficult conversations [i.e., Interpersonal Effectiveness] and that didn’t resonate with me.”

Her observations on changes in herself and her child contextualized some of the quantitative improvements in her own emotion regulation, her parenting and her child’s emotion regulation: “I feel more in tune with my emotions. I feel more centered. I’m able to take a step back to look at family challenges and how we could constructively address them. You get in this pattern of every night we have a 15-minute battle over brushing the teeth. And you can step back and see how do we change this so that we’re not having a battle right before bed every night… [With my child] things have been going really well. My child is able to transition better and talk about their own feelings more, calm themselves down more. They are more able to vocalize when they need to be alone and go for 10 minutes and self-regulate and then come back out. That’s a big difference from throwing a huge tantrum right around you.”

Parent C’s skill implementation was lower than the other two parents, although her compliance with diary card completion was quite high (completing 17 out of 23 diary cards [74%]). She reported using a daily average of 2.93 (SD = 2.26) DBT Skills in nonparenting contexts, a daily average of 2 (SD = 1.69) DBT Skills in parenting contexts, and a daily average of 8.80 (SD = 5.77) parenting skills. Person-specific linear regression models of diary card–reported skill use and of skill use on the DBT-WCCL did not reveal any significant changes over time in DBT or parenting skill use.

Discussion

There is a need for dual generation treatments that intervene on parent and child symptoms and parenting practices and behavior, given their reciprocal links and the persistently high rates of mental health symptoms within families (Everett et al., 2021). Integrating DBT Skills and parent training has been identified as a potentially promising transdiagnostic approach to treating parents and preschoolers who are both experiencing mental health difficulties rooted in emotion dysregulation (Zalewski et al., 2020). The present study developed and tested a DBT Skills + PT program for dually emotionally dysregulated parent-preschooler dyads. By providing DBT Skills to parents, we aimed to improve their emotion regulation and increase their ability to manage stress and difficult emotions in challenging parenting situations. We paired the DBT Skills with parent management training and parental emotion coaching skills training to improve the quality of their parenting (e.g., increasing supportive and decreasing invalidating parenting responses to children’s negative emotions) and their children’s emotion regulation. Our case study had two aims. First, we sought to use idiographic methods to examine week-to-week patterns of change at the individual level in parental emotion dysregulation, child emotion (dys) regulation, and parenting practices. Overall, results of the person-specific linear regressions were in line with our initial hypotheses and showed reductions in both parent and child emotion dysregulation as well as improvements in supportive parenting responses to children’s negative emotions. Specifically, two out of three parents reported large improvements in all three of these domains, and a third parent reported improvements only in supportive parenting. Improvements in all three of these domains are noteworthy as a recent systematic review (Everett et al., 2021) found that only 5 integrated mental health interventions which target both parent mental health symptoms and parenting yielded improvements in parent symptoms, child symptoms, and parenting. Moreover, none of the reviewed interventions focused on parents of preschoolers, a developmental period during which child emotion regulation abilities are rapidly developing (Eisenberg et al., 2010) and which may be particularly challenging for parents who have difficulties with their own emotion regulation. The fact that most of our participating parents showed large improvements in all three domains provides some evidence that DBT Skills + PT is a promising treatment for emotionally dysregulated parents during this key developmental period. The improvements we found are consistent with the promising findings from other studies that have integrated DBT Skills and parenting (Zalewski et al., 2020) and our case study adds to this growing knowledge base on integrating DBT Skills and parenting in important ways. In addition to targeting a different population of dysregulated parents and preschoolers, our intervention paired DBT Skills with two kinds of parenting skills: both Parent Management Training and Emotion Coaching skills. It thus addressed both behavior management skills and emotion socialization techniques, both of which may be more difficult for emotionally dysregulated parents to implement (Maliken & Katz, 2013; Zitzmann et al., 2024). Other DBT + Parenting integration efforts have focused on developing novel treatments (Renneberg & Rosenbach, 2016; Roos et al., 2021). This study’s pairing of skills from two established manuals (Harvey et al., 2015; Linehan, 2015a, 2015b) may help facilitate dissemination and implementation on the part of clinicians who are already familiar with DBT Skills and PT approaches.

The study design also differed from previous DBT and parenting trials by evaluating longitudinal, individual-level trajectories of change in parent ED, child ED, and parenting practices, using idiographic analyses. Idiographic analyses were necessary to reveal individual patterns of change among treatment targets, in ways that a typical pre, mid, and final time point design with aggregated group-level analyses cannot. Proponents of idiographic research have emphasized high levels of heterogeneity in within-individual processes of change (Wright & Woods, 2020). Indeed, our time lagged regressions showed variation in the extent to which end results were achieved, with each parent showing a different process of change. We found partial evidence for our tentative hypothesis of a temporal cascade of improvements in parental ED leading to improvements in parenting, and then to subsequent improvements in child ED. For example, Parent A did show a cascading effect of improvements in her own parental ED preceding improvements in her child’s ED, and of increases in her supportive parenting preceding improvements in her child’s ED. Parent C reported a cascading effect of increases in her supportive parenting preceding improvements in her child’s ED and her child’s ER. Results from these two parents are in line with research on the effects of parental modeling of emotion regulation on their children’s ER (Morris et al., 2007), and of supportive parenting on children’s ER (Eisenberg, 2020).

Some of our results did not align with our initial conceptual models of change. For example, none of the participating parents exhibited a cascading effect of improvements in their own emotion dysregulation preceding improvements in their parenting. This was somewhat surprising due to the established importance of parental emotion regulation to engaging in effective parenting behaviors (Dix, 1991; Hajal & Paley, 2020), and because our treatment front-loaded targeting parental ED by devoting the initial sessions to DBT Skills. In the case of Parent A, not only did her ED improvements not precede her improvements in parenting, but in fact, we found a cascading effect of improvements in her supportive parenting preceding improvements in her own parental ED. While it seems counterintuitive that one’s parenting may impact one’s mental health (and not vice versa), others have theorized that parent training may have benefits for parental mental health because an increased sense of parental self-efficacy may contribute to improved mental health symptoms (such as ED), and because engaging in positive parent-child interactions may serve as a form of behavioral activation that improves mood disorder symptoms (Gonzalez & Jones, 2016). Finally, two more unexpected results were Parent B’s reports of a large linear increase in child ED and Parent C’s reports of a large increase in her own invalidating parenting. These results, which represent a worsening of child symptoms and parenting practices over time, require further comment. With regard to Parent C’s parenting, it is important to note that her mean level of invalidating parenting at baseline was very low (1.53 out of a possible 6) and even with the increase over time, remained very low at follow-up (1.69 of out of a possible 6). The fact that all the rest of her results were in the direction of improvement, that the time-lagged analyses did not indicate that the increase in invalidating parenting was temporally linked to any other outcome, and her qualitative reports of feeling that her parenting had improved, all suggest that this finding was not clinically meaningful. With regard to Parent B’s reported increase in his child’s emotion dysregulation, a number of factors may provide additional context for this surprising result. First, this intervention was provided in the midst of the Covid-19 pandemic, when child mental health problems are known to have increased in general (Theberath et al., 2022). Additionally, Parent B reported that he did not implement many of the skills taught. Results from his person-specific linear regressions indicate that his skill use did not increase over the course of treatment and, in fact, his results point to an increase in the dysfunctional coping subscale of the DBT-WCCL measure of DBT skill use. Parental modeling of emotion regulation is known to impact the development of preschoolers’ emotion regulation abilities and it is possible that some of this parent’s own less effective emotion regulation skills contributed to an increase in his child’s emotion dysregulation. Finally, Parent B reported the highest levels of missing data (completing only 65% of the weekly surveys); therefore, all of his results must be interpreted with greater caution.

In addition to examining patterns of change over the course of treatment, our second aim pertained to treatment development; specifically, the feasibility, acceptability and implementation of DBT Skills + PT. None of the parents dropped out of treatment and all of them exhibited high levels of attendance, despite their noted challenges associated with the pandemic and with the telehealth format. We interpret this as an indication of high feasibility. Parents also reported moderate to very high levels of acceptability in both the quantitative and qualitative results. They also had concrete suggestions for how to improve the intervention: namely, to provide in-person group sessions, to shorten the length of sessions and the duration of the program, and to emphasize some skills (mindfulness, distress tolerance, parenting skills) over others (interpersonal effectiveness). Identifying DBT skills that can both improve a parent’s mental health and simultaneously facilitate improved parenting may be one important way to reduce the 24-week duration and thereby enhance future implementation efforts in community settings. The exit interviews also made clear that improving as a parent was a very strong motivator for all participants. This is also potentially important from an implementation standpoint. Many adults with mental health disorders may not seek treatment for themselves (Corrigan et al., 2014) and may be more motivated to engage in an adult mental health treatment when it is understood to be in the service of their child’s mental health. The motivation around parenting suggests an integrated DBT and parenting intervention might best be provided in the context of community-based parenting programs where parents are seeking help for their child. Finally, implementation levels were high in the current DBT Skills + PT intervention, with average daily DBT skill use levels that were comparable or even much higher (in the case of Parent A) than previous studies on DBT for parents (Martin et al., 2017).

Limitations and Strengths

While this study makes an important contribution to burgeoning efforts to integrate DBT and parenting, it has its limitations. First, we acknowledge that pilot testing with a larger sample size would have been more optimal, as the small sample size of three parents and the case study design does not allow for a sufficiently powered examination of effects. In conducting our quantitative analyses, we have tried to mitigate this limitation by focusing only on large-sized effects which are more likely to represent a reliable indicator of change. This limits our ability to interpret smaller effects, which may be clinically significant. Additionally, the lack of a control group also prevents drawing conclusions regarding the causal effects of treatment, and the changes we found may have also occurred without treatment.

An additional limitation was our exclusive reliance on self-report measures, especially as parental mental health symptoms may influence parent reports on their children’s emotional and behavioral problems (Chi & Hinshaw, 2002). Moreover, all participants knew they were receiving the intervention; thus, expectations regarding its effects (i.e., placebo effect), as well as participants being aware that their behaviors and outcomes were being observed and examined as part of a research study (i.e., Hawthorne effect), may have impacted results. It is also important to note that the three participating parents were all members of two-parent households from higher-than-average SES backgrounds. Further testing of the intervention with more diverse and/or disadvantaged families is needed. Finally, as was the case for many studies in early 2020, our study was disrupted by the Covid-19 pandemic. Given many of the pandemic’s effects on families and, specifically, on the mental health trajectories of parents of young children (Zalewski et al., 2023), it will be important to test this intervention outside the context of the pandemic. In our case, pandemic-related disruptions led to a delay of approximately 5 months between the intake and the initial baseline assessment. During this time, all three parents experienced relatively large decreases in their own parental emotion dysregulation. Thus, although all three parents had been very emotionally dysregulated when they entered the study at intake (up to 2 standard deviations above a normative level), only one of the three (Parent A) was experiencing elevated ED during the treatment phase. Changes in parental ED over the course of treatment must be considered with this in mind.

This study has a number of important strengths. The DBT Skills + PT group therapy program represents an integrated intervention that targets multiple domains (both adult mental health and parenting practices linked to children’s mental health) and that is aimed at a specific, underserved transdiagnostic population of parent-preschooler dyads. The intervention was developed with a strong theory of change, which sees parental emotion regulation as underpinning the effective parenting needed to foster the development of preschooler emotion-regulation abilities. The use of two well-established manuals may enhance dissemination and implementation efforts. Finally, in addition to targeting multiple domains, our study design also measured these three domains (parent ED, parenting practices, child ED) longitudinally and used advanced idiographic analyses to test the cascade of effects and generate future hypotheses about mechanisms of change.

Conclusion and Future Next Steps

This study provides support for the further development of DBT Skills + PT as a promising treatment for parents who struggle with emotion regulation and whose preschool-aged children also exhibit emotional and behavior difficulties. Overall, most parents were engaged in the program and felt they and their children had benefited from it. Future development efforts should include a controlled trial with a larger sample size and a more racially and socioeconomically diverse population of parents to test the effectiveness of the DBT Skills + PT intervention. Additionally, a multimethod approach to data collection that includes multiple informants on child behavior (e.g., teachers) and observational measures of child behavior and parenting behavior should be incorporated into such a future effectiveness study. While the intervention is intended to be transdiagnostic, it may also be valuable to test it with a population of parents experiencing a similar set of mental health struggles (for example, emotionally dysregulated parents with substance use difficulties or with high levels of parenting stress), that are known to be linked to specific child mental health symptoms (for example, externalizing behaviors). This would help in assessing likely mechanistic pathways between parent and child symptoms. The long-term goal is that the promising results from our case study establish some of the groundwork necessary for larger-scale, more sufficiently powered trials in order to test the intervention’s effectiveness and the mechanisms by which DBT Skills + PT may improve the mental health of parents and their preschool-aged children.