DBT skills + parent training for preschool parents with emotion dysregulation and substance misuse

Abstract

Background

Parenting and substance use recovery often intersect, as many adults accessing substance use disorder (SUD) treatment are also parents. Critically, parental SUDs are a risk factor for poorer parenting behaviors, with downstream impacts on child mental health. However, extant evidence-based interventions do not target proximal, parent-specific relapse risk factors (e.g., parental emotion dysregulation [ED], parenting stress), and relapse risk remains high. We sought to address this by integrating best practices in SUD, ED, and parenting interventions to expand reach and improve outcomes.

Methods

This pilot study assessed feasibility, acceptability, and preliminary efficacy of a 20-week Dialectical Behavior Therapy Skills + Parent Training (DBT Skills + PT) telehealth group intervention for parents in SUD remission with elevated ED. Participants were 12 parents (11 mothers) of preschool-aged children (5 female).

Results

Intervention feasibility (i.e., attendance, attrition, diary card compliance) and acceptability (i.e., satisfaction, skills use) were high. All treatment-completers maintained their SUD remission and reported large reductions in ED, child behavior problems, negative parenting behaviors, and parenting stress. Quantitative results were corroborated by qualitative feedback provided at an exit interview.

Conclusions

The present findings support further larger scale testing of DBT Skills + PT as a promising intervention for parents in SUD remission with elevated ED, with prospective intergenerational impacts.

Supplementary information

The online version contains supplementary material available at 10.1186/s40479-026-00343-5.

Introduction

Nearly 60% of adults who receive treatment for substance use disorders (SUDs) are parents [1] , and approximately 1 in 8 children live with a parent who misuses a substance [2]. Many of these children are aged five and under (i.e., 35.9% [3]), a developmental window when parental influence is especially salient [4, 5]. Parental substance misuse is associated with parenting behaviors that may negatively impact a child [6–8]. For instance, parental alcohol misuse is associated with lower parental warmth and sensitivity, which in turn prospectively predicts poorer child self-regulation and externalizing problems [9]. Poorer parenting behaviors are one pathway that may explain intergenerational risk, as children of parents with SUDs are estimated to be 2–3 times more likely to develop mental health challenges themselves [10]. The prevalence of parental substance misuse, which increased during the COVID-19 pandemic [11, 12], along with its downstream effects on children, remains a major public health concern. Notably, this issue may persist even among parents accessing treatment, as nearly half of patients with SUDs relapse following recovery [13].

Stress is a proximal risk factor for SUD relapse [14], as SUD-related alterations in stress reactivity can drive coping-oriented substance use [15]. Parenting stress, a conceptually distinct type of stress related to the parental role [16], may uniquely impact those with a history of SUDs. For example, difficult parent-child interactions, a source of parenting stress, can increase craving for substances [17]. Moreover, maladaptive coping strategies and elevated parenting stress may interact to increase maternal alcohol use [18]. Levels of parenting stress often peak during the preschool period, and evidence points to reciprocal relationships between parenting stress, parenting quality, and child behavior problems [19]. Children of parents with a history of substance misuse may be more likely to exhibit behavior problems associated with reduced parenting quality and increased parental substance misuse [20, 21]. Specifically, preschoolers’ aggressive behaviors and response to parental discipline may elicit harsher parenting from mothers with alcohol dependence [22], and toddlers’ behavior problems prospectively predict maternal cannabis misuse [23].

In addition, elevated emotion dysregulation (ED) is a prevalent symptom among individuals with SUDs and a key risk factor implicated in SUD relapse [15, 24]. Similar to parenting stress, elevated parental ED is reciprocally associated with parenting quality and child emotional and behavioral problems [5]. Parents with elevated ED may model poorer effective emotion regulation strategies [5, 25] and may engage in less effective parenting behaviors [26]. In turn, their children may be at increased risk for emotional and behavioral problems [27]. Thus, for parents with a history of substance misuse, elevated ED may increase relapse risk and have negative effects on child development. Families affected by the reciprocal associations between parental substance misuse, parenting stress, elevated parental ED, and child emotional and behavioral problems may require interventions that simultaneously address each interlinked domain.

Parent training for parents with psychopathology & SUDs

Parent training (PT) interventions address several key factors relevant to substance misuse and relapse risk, including parenting stress and child emotional and behavioral problems [28]. PT interventions often target one of two categories of parenting behaviors in an effort to reduce child emotional and behavioral problems: 1) parent behavior management focuses on reinforcement and consequences to increase positive and decrease negative child behavior, and 2) parent emotion socialization focuses on supportive responses to child emotional expression. Several PT interventions targeting these parenting behaviors have achieved “gold standard” status [29–31]. Despite their overall effectiveness, PT interventions are less effective for parents who struggle with elevated ED and substance misuse [32–34], as these challenges may hinder parents’ ability to implement consistent limit-setting and respond effectively to their child’s dysregulation [26]. Thus, there is growing interest in integrated interventions, which simultaneously address both sets of parenting behaviors (i.e., parent behavior management and parent emotion socialization), parental ED, and parental SUDs [35].

Dialectical behavior therapy (DBT) for adults with SUDs

DBT is an evidence-based intervention focused primarily on improving emotion regulation [36]. Parental ED is increasingly identified as a transdiagnostic factor with negative intergenerational impacts [5], and efforts have been made to apply DBT to parent populations and incorporate PT [37]. However, these efforts have not been extended to parent populations with SUDs. DBT Skills have been adapted specifically for adults with SUDs (DBT-SUD) by incorporating skills that promote abstinence and reduce the length and adverse impacts of relapse [38]. Several randomized controlled trials of DBT-SUD for adults with SUDs and elevated ED provide evidence for the treatment’s efficacy [39, 40] across a range of SUDs, including robust impacts among those struggling with Opioid Use Disorder, Alcohol Use Disorder, and Polysubstance Use Disorder [41, 42]. Despite this and the fact that most adults treated for SUDs are parents, DBT adaptations do not consider the unique needs of parents in SUD remission, including parenting-specific relapse risk factors (e.g., parenting stress and child emotional/behavioral problems). Future efforts to develop and test integrated DBT Skills + PT programs [43] [44, 45], must be extended to parents with elevated ED and SUDs, and such was the purpose of the current study.

Current study

We conducted a pilot 20-week DBT Skills + PT group intervention for 12 parents in SUD remission with elevated ED. DBT Skills + PT aims to target proximal risk factors for SUD relapse, parent and child mental health challenges, parenting behaviors, and parenting stress. Using a mixed-methods design, primary and secondary outcomes were explored. Our main aim evaluated the feasibility and acceptability of telehealth-delivered DBT Skills + PT for parents in SUD remission with elevated ED. Preliminary intervention efficacy was also explored by examining secondary outcomes. including parent mental health, child mental health, parenting behaviors, and parenting stress, through weekly assessments of overall change and pre-post treatment effects.

Methods

Participants

The baseline sample consisted of 12 parents (11 mothers; 58% White; 33% multiethnic and/or multiracial; 9% Mexican-American; M_age = 33.75, SD_age = 6.08) and their preschool-aged child (5 females; M_age = 4.67, SD_age = 1.37). Parent education level varied, including high school graduates (16%), parents with some college and no degree (42%), and parents with a bachelor’s degree (42%). No parents were married, six reported being in a serious relationship, and six were single. On average, parents had 2 children (range = 1–4).

Parents met DSM-5 criteria for at least one SUD in the past 5 years, but not in the past 12 months. Diagnoses included Alcohol (n = 10), Stimulant (n = 5), Opioid (n = 4), Sedative (n = 3), and Cannabis (n = 3) use disorder. On average, parents met criteria for 2.08 past SUDs (SD = 1.08, range = 1–4). In addition to parents being in SUD remission, some met criteria for current DSM-5 diagnoses (Generalized Anxiety Disorder; n = 5, Social Anxiety Disorder; n = 4, Major Depressive Disorder; n = 4, ADHD; n = 4, Post-traumatic Stress Disorder; n = 3, Agoraphobia; n = 2, Binge-eating; n = 1, Adjustment Disorder; n = 1, Specific Phobia; n = 1). Four parents did not meet criteria for a current mental health disorder, one parent met criteria for a single mental health disorder, and seven parents were characterized by comorbidity. The research team withdrew one parent from the study after a single session, due to a change in eligibility. They were not included at follow-up. Three parents stopped treatment (i.e., with one lost to follow-up and two who completed the follow-up assessment). Eight parents completed the entire group intervention¹.

Procedure

This study was conducted at a university in the Pacific Northwest of the United States. Recruitment began in April 2021, involved a variety of methods (e.g., university departmental database, social media, direct mailing via Early Head Start), and occurred continuously to facilitate running three groups with two to four members per group. Groups ran at different times, occurring between July 2021 and September 2022. Clinical intakes and group sessions were conducted via the HIPAA-compliant Zoom platform. All survey data collection occurred using online Qualtrics questionnaires. Study procedures were IRB-approved and in accordance with the Declaration of Helsinki, and the study protocol was registered on clinicaltrials.gov (NCT05287178) on March 18, 2022. All participants provided consent to study procedures at the time of intake.

Parents completed an online screening survey to determine eligibility. To be eligible, parents had to be 18+ years of age, receive a score of > 88 on the Difficulties with Emotion Regulation Scale (DERS [46]), and meet a cutoff on an adapted version of the CAGE-AID screener for drug and alcohol problems, which asked about substance use in the past 5 years and the past 12 months [47]. On the CAGE-AID, parents had to endorse ≥ 2 symptoms of substance use problems in the past 5 years and ≤1 symptom in the past 12 months. Time period criteria were selected to reflect the potential overlap between parental SUDs occurring within the lifetime of the target preschool-aged child and a current status of SUD remission, while also considering risk in the context of a pilot study. At screening, parents confirmed: they resided in the state where treatment occurred, they had custody of their preschool-aged child (3–6 years old; at least partial custody), no known developmental disabilities (child and parent), English proficiency, they had internet access necessary to participate in a remote telehealth intervention, and their ability to attend group at scheduled times.

Parents completed an online screening survey to determine eligibility. To be eligible, parents had to be 18+ years of age, receive a score of > 88 on the Difficulties with Emotion Regulation Scale (DERS [46]), and meet a cutoff on an adapted version of the CAGE-AID screener for drug and alcohol problems, which asked about substance use in the past 5 years and the past 12 months [47]. On the CAGE-AID, parents had to endorse ≥ 2 symptoms of substance use problems in the past 5 years and ≤1 symptom in the past 12 months. Time period criteria were selected to reflect the potential overlap between parental SUDs occurring within the lifetime of the target preschool-aged child and a current status of SUD remission, while also considering risk in the context of a pilot study. At screening, parents confirmed: they resided in the state where treatment occurred, they had custody of their preschool-aged child (3–6 years old; at least partial custody), no known developmental disabilities (child and parent), English proficiency, they had internet access necessary to participate in a remote telehealth intervention, and their ability to attend group at scheduled times.

Parents who met the screening criteria were invited for a clinical intake, which included the Structured Clinical Interview for DSM-5 (SCID-5 [48]), administered by a master’s level-clinician. Parents had to meet criteria for a SUD in the past 5 years for any of the following DSM-5 defined disorders: alcohol, cannabis, hallucinogenic, inhalant, opioid, stimulant, or sedative/hypnotic/anxiolytic. Parents were excluded at intake if they met criteria for a SUD in the past 12 months, had a verbal ability score of < 70 on the Peabody Picture Vocabulary Test (PPVT-5) (an indicator of intellectual and developmental disability), endorsed symptoms of psychosis on the SCID-5, endorsed suicidal ideation with an active plan, or if clinical judgment suggested a higher level/different form of care was indicated.

Eligible parents completed a set of pre-intervention measures approximately 1 week before treatment began to establish baseline scores on assessments of parent and child mental health, parenting behaviors, and parenting stress. The group intervention consisted of 20 weekly telehealth sessions, with parents completing weekly self-report measures 1–2 days prior to each group session. At the end of treatment, parents completed a set of follow-up measures and a 60-minute exit interview, including the SCID-5 substance use disorder module, to assess for potential relapse of SUD symptoms during treatment, and qualitative questions about their experience with the intervention. Exit interviews were conducted by a master’s-level clinician who was not a group therapist.

Baseline, weekly, and follow-up measures included a battery of parent-report measures assessing parent and child mental health, parenting behaviors, parenting stress, and parental skills use². Parents were compensated for completing baseline, weekly, and follow-up assessments, as well as exit interviews; compensation for weekly assessments was provided regardless of group therapy attendance.

Intervention

The group intervention integrates DBT Skills with Parent Management Training and Emotion Socialization components³. The DBT Skills portions of each session followed the DBT Skills Training Manual, Second Edition [49], and the DBT Skills Training Handouts and Worksheets, Second Edition [49]. DBT Skills from each of the four modules (i.e., Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness; see Supplementary material for outline of Session Plan) were covered. PT followed the Parenting Hyperactive Preschoolers Clinician Guide [50]. This evidence-based PT intervention was selected because it integrates and targets both important domains of Parent Training: parent behavior management and emotion coaching [51]. Group sessions were 2.5 hours long, including a mindfulness practice, homework review to discuss the use of learned skills, a 10–15-minute break, didactics on new DBT + PT skills, and homework assignment. The present DBT Skills + PT group intervention was informed by experiences from a previous DBT Skills + PT case study [43]. Modifications included a reduction in treatment duration by excluding select DBT Skills (e.g., repetition of Mindfulness module), and two sessions were devoted to DBT Skills for addictive behaviors. Children were not engaged in treatment.

Interventionists

Five DBT Skills co-leaders (i.e., one male and four female) led three parent groups, with two co-leaders assigned to each group. Co-leaders were master’s-level therapists enrolled in a clinical or counseling psychology doctoral program. Therapists participated in 70 hours of didactics to learn the full treatment model and received in-depth training on the second edition of the DBT Skills Training Manual [49]. Therapists received supervision and participated in weekly consultation team with a a licensed psychologist, skilled in DBT and PT.

Measures

Primary outcomes

Feasibility & acceptability

Intervention feasibility was assessed via attendance and attrition rates, as well as diary card compliance. Intervention acceptability was assessed using a mixed methods approach, including parent self-report of satisfaction with the intervention, qualitative feedback provided during an exit interview, and self-reported skill use.

The Client Satisfaction Questionnaire (CSQ-8 [52]); was completed at follow-up (α = 0.96) as a quantitative measure of intervention acceptability. This brief 8-item self-report measure asks clients to rate their satisfaction with the intervention on a Likert scale of 1–4. Scores range from 8 to 32, with higher scores indicating higher levels of satisfaction.

A semi-structured qualitative exit interview was also used to assess intervention acceptability, including1) challenges experienced completing the intervention, 2) use of DBT/PT skills, and 3) suggestions for improving intervention delivery. Interviews were video recorded and transcribed to identify representative quotes and themes.

The DBT Ways of Coping Checklist (i.e., DBT-WCCL [53]); is a 38-item self-report measure assessing the frequency of DBT Skill use. Parents completed the DBT-WCCL at baseline (α = 0.92), follow-up (α = 0.91), and at each weekly timepoint as an indicator of acceptability (i.e., engagement with and use of intervention components).

A diary card was developed for this study by the research team and used for treatment purposes, as well as to assess intervention feasibility (i.e., diary card compliance) and acceptability (i.e., skills use). Parents were asked to mark the days of the week on which they used each skill and to indicate whether DBT Skills were used in a parenting or non-parenting context. Diary cards for this study were primarily skills focused and not aimed at monitoring problem behaviors. Participants completed the Diary Card via Qualtrics at each weekly timepoint.

Secondary outcomes

Parent & child mental health

The Difficulties with Emotion Regulation Scale (DERS [46]); is a 36-item self-report measure used to assess ED. Items are rated on a scale of 1 to 5, with higher scores indicating higher levels of ED. Parents completed the DERS at baseline (α = 0.78), follow-up (α = 0.78), and at each weekly timepoint.

The Patient Health Questionnaire–depression module (PHQ-9 [54]); is a 9-item self-report measure in which participants rate how often depressive symptoms have bothered them in the past 2 weeks, on a scale of 0 (Not at all) to 3 (Nearly every day). Summed total scores range from 0 to 27, with higher scores indicating higher levels of depressed mood. Parents completed the PHQ-9 at baseline (α = 0.93) and follow-up (α = 0.65).

The Hamilton Anxiety Scale (HAM-A; [55]) is a 14-item self-report measure assessing physical symptoms of anxiety. Subjects rate the severity of symptoms ranging from 0 (Not present) to 4 (Very Severe). Scores are summed for a total score ranging from 0 to 56, with higher scores indicating higher levels of anxiety. Parents completed the HAM-A at baseline (α = 0.93) and follow-up (α = 0.86).

The Aggregated Drug Craving Scale (ADCS [56]); is an adaptation of the Penn Alcohol Craving Scale (PACS [57]); and measures a broad range of substance cravings. The measure includes five items assessing intensity, frequency, and duration of craving, the ability to resist substances if available, and an average craving rating for the past week. Responses range from 0 to 6 for each item, with higher scores indicating greater cravings. Parents completed the ADCS at baseline (α = 0.91) and follow-up (α = 0.90).

The Emotion Regulation Checklist (ERC [58]); is a 24-item parent-report measure in which parents use a Likert scale of 1–4 to rate how characteristic of their child certain statements are. The measure produces two subscales (i.e., lability/negativity and emotion regulation) and a composite of the two. Parents completed the ERC at baseline (lability/negativity; α = 0.56, emotion regulation; α = 0.68, composite; α = 0.75) and follow-up (lability/negativity; α = 0.81, emotion regulation; α = 0.79, composite; α = 0.89). The Weekly Assessment of Child Behavior (WACB [59]); is a 9-item parent-report measure in which parents rate how often their child engages in positive behaviors on a weekly basis, using a Likert scale of 1–7. The measure is based on the positive opposites of behaviors measured by the Eyberg Child Behavior Inventory (ECBI) and yields two scales: Intensity and Need-to-Change. The measure has demonstrated strong convergent validity with other established measures of child behavior problems. Parents completed the WACB at baseline (α = 0.86), follow-up (α = 0.84), and at each weekly time point.

The Child Behavior Checklist (CBCL [60]); is a 99-item parent-report measure of child emotional and behavioral problems and yields subscales for both internalizing and externalizing problems. Higher scores indicate greater problems. Parents completed the CBCL at baseline (internalizing; α = 0.92, externalizing; α = 0.87) and follow-up (internalizing; α = 0.85, externalizing; α = 0.95).

Parenting behaviors

The Parenting Scale (PS [61]); is a 30-item self-report measure asking parents to indicate how they respond to various child misbehaviors, using a Likert scale of 1–7. It yields three subscales: laxness, over-reactivity, and verbosity. Parents completed the PS at baseline (α = 0.86), follow-up (α = 0.94), and at each weekly timepoint. The verbosity subscale was only examined in weekly analyses (α = 0.84) due to low baseline reliability.

The Coping with Children’s Negative Emotions Scale (CCNES; [62]) is a parent-report measure assessing emotion socialization parenting behaviors. Parents are presented with 12 vignettes describing scenarios in which their children exhibit distress. Using a Likert scale of 1–7, parents rate the likelihood they would respond to the situation in 6 potential ways, with each response corresponding to a subscale: Distress reactions, punitive reactions, and minimization are summed to create a non-supportive parenting composite, and expressive encouragement, emotion-focused reactions, and problem-focused reactions are summed to create a supportive parenting composite. Parents completed the CCNES at baseline (non-supportive; α = 0.84, supportive; α = 0.92) and follow-up (non-supportive; α = 0.90, supportive; α = 0.97). The CCNES was included in weekly assessments for the seven parents in intervention groups 2 and 3.

Parenting stress

The Parenting Stress Index Short-Form (PSI-4 SF [63]); is a 36-item parent-report measure of parental stress, rated on a five-point Likert scale. Normative scores have been established. Raw scores are converted to T-scores and percentiles for interpretation. Parents completed the PSI-4 SF at baseline (α = 0.94) and follow-up (α = 0.93).

Data analytic plan

Aim 1 was to assess the intervention feasibility and acceptability. Intervention feasibility was assessed via attrition and attendance rates and overall weekly diary card compliance. Acceptability was determined by averaging total satisfaction scores from the CSQ-8 at follow-up and by summarizing qualitative exit interview data. Additionally, z-scored average weekly change in reported skills use at the group level was descriptively examined as a behavioral indicator of acceptability, reflecting continued engagement with and perceived utility of skills.

To explore secondary outcomes and evaluate the effect of DBT Skills + PT on pre/post parent and child mental health, parenting behaviors, and parenting stress, group-level means and standard deviations at baseline and follow-up were used to conduct paired sample t-tests and to calculate corresponding effect sizes (Cohen’s d). Because the current study aligns more closely to an efficacy trial examining the effect of DBT Skills + PT under optimal conditions, results focus on treatment completers. Z-scored average weekly change in secondary outcomes at the group level were descriptively examined (i.e., excluding parenting stress). Themes in qualitative feedback obtained at follow-up pertaining to pre-post changes in secondary outcomes were summarized, to further understand quantitative findings.

Results

Primary outcomes

Feasibility & acceptability

Among parents enrolled to participate in treatment (n = 12), one was withdrawn by study staff following the first group session, as they no longer resided in the state in which therapy was being conducted. Three of the remaining 11 parents (27%) discontinued treatment after having attended between 1 and 4 sessions. Treatment completers (n = 8) attended an average of 86.25% (SD = 15.75) of 20 total sessions. Overall, weekly diary card compliance for treatment completing parents was 78.5%. One treatment completer did not complete any diary cards and, thus, was excluded from analysis.

Mean satisfaction at follow-up among the full sample (n = 9), assessed via the CSQ-8, was 29.50 (SD = 4.45) out of 32 possible points. For treatment completers (n = 8), mean satisfaction was 30.75 (SD = 2.81). Additionally, several themes pertaining to acceptability emerged from parent feedback provided at follow-up. First, parents endorsed an interest in improving their ability to manage their emotions in the context of parenting as a key motivator for participation in DBT Skills + PT. Second, when describing intervention skills they found most helpful, parents shared that mindfulness (DBT) and praise/positive attention (PT) were particularly impactful. In contrast, parents described skills for addictive behaviors (DBT) and rewards charts (PT) as least helpful. Parents also made suggestions for ways in which future iterations of DBT Skills + PT may be improved, including preference for in-person groups, homework reminders to increase skill use, and shorter group sessions. Appendix C (see Supplementary material) further summarizes exit interview topics, provides additional synthesis of parent feedback, and includes selected quotes to illustrate findings as related to acceptability.

Parent-reported DBT skills use revealed an average increase of approximately 2SD over the course of treatment (i.e., n = 7; seven parents completed 10 or more weekly surveys and were thus included in analysis). Among treatment-completing parents who completed diary cards, a daily average of 2.56 (SD = 2.32) DBT Skills were used in non-parenting contexts, and 1.53 (SD = 1.85) DBT Skills were used in parenting contexts. Parents also reported using a daily average of 4.03 (SD = 3.65) PT skills.

Secondary outcomes: treatment efficacy

Pre/post treatment effects, including outcome means and standard deviations for treatment completers (n = 8) are presented in Table 1. Findings for the full sample (n = 12) are presented in Appendix D (see Supplementary material). Seven parents completed 10 or more weekly surveys and were thus included in analyses of weekly change in parental ED, child behaviors, and two aspects of negative parenting behaviors - one measuring emotion socialization behaviors (i.e., non-supportive parenting) and one measuring parent management behaviors (i.e., dysfunctional discipline). Appendix E (see Supplementary material) provides means and standard deviations for each weekly variable.

Table 1.

Means, SDs and effect sizes of changes at baseline and follow-up timepoints for treatment completers

Measure	Baseline			Follow-up
	Mean	SD	N	Mean	SD	N	d [CI]
Parent Outcomes
Emotion Dysregulation (DERS)	111.25	15.34	8	57.88	19.61	8	−3.24 [−5.14, −1.29]
Substance Craving (ADCS)	9.38	4.81	8	7.75	7.23	8	−0.28 [−1.26, 0.72]
Depression (PHQ-9)	9.62	5.90	8	3.75	1.67	8	−1.45 [−2.65, −0.19]
Anxiety (HAM-A)	16.00	8.21	8	8.88	4.39	8	−1.16 [−2.27, 0.02]
Child Outcomes
Externalizing Behaviors (CBCL T-score)	49.00	9.81	8	41.50	7.80	8	−0.90 [−1.96, 0.21]
Internalizing Behaviors (CBCL T-score)	52.00	12.92	8	45.50	8.98	8	−0.62 [−1.64, 0.43]
Emotion Lability/Negativity (ERC-LN)	25.00	3.70	8	21.50	5.15	8	−0.83 [−1.88, 0.26]
Emotion Regulation (ERC-ER)	35.75	2.38	8	39.12	2.85	8	1.38 [0.14, 2.55]
Parenting Behaviors
Total Dysfunctional Discipline (PS)	3.72	0.53	8	2.60	0.80	8	−1.78 [−3.08, −0.41]
Laxness (PS)	3.82	1.07	8	2.54	0.67	8	−1.54 [−2.76, −0.25]
Over-reactivity (PS)	3.31	0.65	8	2.26	0.93	8	−1.40[−2.58, −0.15]
Non-supportive Parenting (CCNES)	2.61	0.66	8	2.01	0.55	8	−1.06 [−2.15, 0.09]
Supportive Parenting (CCNES)	5.50	0.61	8	6.08	0.66	8	0.97 [−0.16, 2.04]
Parenting Stress
Parenting Stress (PSI percentile score)	66.25	13.83	8	39.25	16.10	8	−1.92 [−3.28, −0.50]

Parent & child mental health

Pre-post analyses showed a large reduction in parental ED (d = −3.24) and symptoms of depression (d = −1.45) and anxiety (d = −1.16). On average, weekly changes revealed that parental ED decreased by approximately 4SD over the course of treatment (Fig. 1). Themes in qualitative feedback obtained at follow-up corroborated the overall reduction in parental ED (Appendix C; see Supplementary material). One parent described how “in situations where I would have gotten very emotional, I’m now able to calm myself down.” Additionally, parents described reductions in ED specific to parenting contexts: “I’ve been more able to stay calm when overwhelming behaviors from my son [come up], where before I would escalate pretty quickly”. A small reduction in substance use craving (d = −0.28) also emerged. Diagnostic interviews conducted with treatment completers at study follow-up revealed that all parents maintained SUD remission status, with no increase in SUD symptoms across the intervention.

Fig. 2.

Participant CONSORT flow diagram

Fig. 1.

Z-scored average weekly change in 4 domains across baseline, 20-weeks of treatment and follow-up assessment: (top left) decreases in non-supportive parenting behaviors, (bottom left) decreases in parental dysfunctional discipline, (top right) decreases in parental emotion dysregulation, and (bottom right) increases in child positive behavior

From baseline to follow-up, child mental health showed overall improvements, including large improvements in emotion regulation (d = 1.38), large reductions in externalizing problems (d = −0.90), medium reductions in internalizing problems (d = −0.62), and large reductions in ED (d = −0.83). Weekly average changes revealed that child positive behaviors increased by approximately 3SD over the course of treatment (Fig. 1). At the follow-up exit interview, parents described improvements in their child’s ability to communicate about and express their emotional experience (Appendix C; see Supplementary material). For example, one parent noted, “He’s been more vocal about talking about how things are affecting him emotionally and how he’s feeling.” Another parent shared: “Labeling emotions has been a really big change I’ve noticed in her. She’s been able to communicate and say, ‘When I’m feeling angry, I’d like it if you’d pat my back.’ She’s able to communicate her needs more clearly and express her emotions more freely.”

Parenting behaviors & parenting stress

Parenting behaviors improved from baseline to follow-up, with large reductions in total dysfunctional discipline (d = −1.78), parental laxness (d = −1.54), and parental over-reactivity (d = −1.40). Parental emotion socialization behaviors improved as well, including large reductions in non-supportive parenting (d = −1.06) and large increases in supportive parenting (d = 0.97). Pre-post analysis also revealed large reductions in parenting stress (d = −1.92). Over the course of treatment, weekly average changes revealed that dysfunctional discipline and non-supportive parenting both decreased by approximately 3SD (Fig. 1). At the follow-up exit interview, qualitative themes in the feedback provided included parents’ improved ability to be more present and respond more effectively to their child’s emotions (Appendix C; see Supplementary material). Two selected quotes illustrating these themes are as follows: 1) “Before, I would automatically shut down, close off and withdraw emotionally from situations where [my daughter’s] expressing a difficult emotion. Now I’m able to take a breath and sit with that moment and think, ‘What does she need from me right now?’ I’m much more able to sit there with her, be present with her. Not try to change it or cheer her up. It’s ok to feel that way and just be there with her in it”, and 2) “I notice I yell a lot less with my kids. That was a big goal going in … I have control in directing how [situations] turn out based on my own reactions and what I model for them. The validating piece was huge for me, bringing that into our conversations instead of just giving them orders.”

Discussion

Adults in remission from SUDs with elevated ED are at higher risk of relapse, and many of these individuals are parents. Importantly, for parents, this risk may be exacerbated by parenting-specific relapse riskfactors such as high levels of parental ED and parenting stress, commonly experienced during the preschool period. Parental ED is linked to less effective parenting behaviors and poorer parental modeling of emotion regulation, which may, in turn, increase the risk for child emotional and behavioral problems and reciprocally impact parenting stress. As a result, calls have been increasingly made for integrated adult mental health and PT interventions, which specifically target these interlinked domains, including elevated ED, SUDs [64], and parenting-specific relapse risk factors. The current pilot study sought to meet this need by applying a 20-week DBT Skills + PT group intervention with 12 parents in SUD remission with elevated ED, to expand reach and improve intergenerational outcomes. The study sample was transdiagnostic, as parents exhibited levels of ED at approximately 1.5SD above the established norm [65] and reported a wide range of past SUD diagnoses and current mental health disorders.

Our first aim assessed intervention feasibility and acceptability by evaluating client attrition and attendance rates, daily diary card compliance, parents’ reported satisfaction, use of DBT and PT skills, and quantitative and qualitative feedback provided at study follow-up. The DBT Skills + PT group intervention was highly feasible, with attendance rates similar to or greater than average attendance rates reported in extant DBT Skills trials (e.g. [66]). In addition, attrition rates were comparable to those found in trials of non-integrated DBT Skills (e.g. [67], [68, 69]); and outperformed attrition rates in PT programs with high-risk families and parents with psychopathology (e.g. [34, 70]). Research on Parent-Child Interaction Therapy suggests that parents who struggle with managing stress and ED in parenting contexts are more likely to disengage from parent training [71]. By directly targeting these parental mental health challenges, DBT Skills + PT may have achieved lower rates of attrition than those found in other non-integrated programs. Qualitative feedback from treatment-completing parents may suggest that future studies further bolster feasibility via offering in-person options for participation with a childcare component. Furthermore, DBT Skills + PT diary card compliance among treatment-completing parents was consistent with that reported in previous DBT trials (e.g. [72, 73]).

Additionally, intervention acceptability was high. Parents reported high satisfaction on the quantitative measure, indicating that parents believed DBT Skills + PT had benefited them in many of the ways they had hoped. Qualitative feedback supported this finding, as parents expressed enthusiasm for the intervention and described positive changes in themselves, their parenting, and their child, many of which corresponded with initial goals when entering DBT Skills + PT. As this is a DBT Skills + PT treatment development study for parents in SUD remission, parents’ feedback on helpful aspects of the program and suggestions for improvement provided important information for future iterations.

A theme which emerged from parent qualitative feedback regarding shortening the length of group sessions requires further consideration as it may necessitate paring down on skills taught over the course of treatment. Within the study of DBT, there are active studies examining the extent to which DBT can be abbreviated while still maintaining fidelity to the treatment model [74]. Nonetheless, abbreviated versions of DBT and DBT Skills show promising results (e.g. [75–77]). Insights provided regarding the most/least helpful skills could aid in selecting which to retain (Appendix C; see Supplementary material), with the aim of reducing the burden and increasing intervention acceptability without undermining effectiveness.

To this end, parent qualitative feedback may suggest that future iterations of DBT Skills + PT emphasize Mindfulness, Distress Tolerance, and Emotion Regulation skills, along with the use of praise, positive attention, effective commands, consequences, and labeling and validating emotions. Parent feedback suggested less focus on Interpersonal Effectiveness skills and Reward charts. An interesting point of feedback emerged regarding DBT Skills for addictive behaviors. Parent feedback was mixed on this set of skills. This feedback may be due to variability in the length of each parent’s SUD remission status, which ranged from 12 months to nearly 5 years. Future studies on DBT Skills + PT for parents in SUD remission may focus on a narrower timeframe of SUD remission (e.g., parents in early remission; 3–12 months). As 65–75% of people in early SUD remission relapse within the first year following treatment [78, 79]. Testing the intervention among a more stratified sample would allow for a better evaluation of acceptability and the extent to which DBT Skills + PT may prevent relapse.

Participant-reported skills use also suggested strong engagement with and use of intervention components, with average weekly use of DBT Skills increasing over the course of the 20-week intervention. The intervention taught parents to use PT skills in addition to DBT Skills, and yet the overall average weekly skills use reported via diary card (i.e., both DBT and PT skills) was similar to rates of DBT skill use found in a non-integrated DBT Skills intervention for parents (i.e., 7–8 skills [73]. This may suggest limitations in parents’ ability to implement, recall, and/or report the use of more than 7–8 skills/day on the diary card measure. To further elucidate this behavioral proxy of DBT Skills + PT acceptability, future efforts may include additional real-time measures of skill use [80, 81].

Secondary outcomes explored via an examination of weekly assessment measures and pre-post treatment effects on parent and child mental health, parenting behaviors, and parenting stress showed improvements with medium to large effect sizes across each interlinked domain. When compared to improvements reported in extant literature, pre-post effects of DBT Skills + PT revealed a greater magnitude of improvement in ED and symptoms of depression and anxiety (see [82] for systematic review and meta-analysis [83]), as well as all parenting behaviors and parenting stress [45, 84–86]. In addition to sizable pre-post effects, current findings regarding parent mental health and parenting behaviors were supported by an examination of weekly assessments. Findings demonstrate that treatment-completing parents showed a reduction in overall ED, non-supportive parenting, and dysfunctional discipline ranging from approximately 2-4SD across the intervention. Qualitative themes support these findings, including parents’ improved ability to manage their own emotions, be less reactive, be more present with their child, and respond more effectively to their child’s negative emotions.

Findings regarding improvement in child mental health following parent participation in DBT Skills + PT underscore prospective intergenerational impacts, including medium to large effects across all domains (i.e., child emotion (dys)regulation, emotional and behavioral problems). While effects on child behavioral problems were smaller than those found in the BRIDGE integrated DBT + Parenting intervention [45], effects on child ED outperformed previous reports [84], and overall effects on child mental health proxies were similar to effects reported by non-integrated parenting programs [85, 86]. Consistent themes in qualitative feedback emerged, highlighting improvements in children’s ability to express negative emotions in non-destructive ways.

Given the focus on applying DBT Skills + PT to a SUD population, further evaluation of change in substance use outcomes is warranted. Previous trials of DBT Skills for SUDs have shown larger improvements in SUD symptoms than those found in the current DBT Skills + PT integration (see [82], [83]). While the current study chose to focus on substance craving because of parental remission status, many SUD outcome measures have been developed for use in clinical trials [87]. A future efficacy trial may examine a broader range of SUD outcomes (e.g., toxicology analyses, interviews on the amount and frequency of use, and measures of functioning). Of note, diagnostic interviews conducted at follow-up provided evidence supporting that all treatment-completing parents maintained their SUD remission status and did not relapse. It is possible that the variability in the length of parents’ SUD remission (i.e., between 12 months and 5 years) contributed to remission maintenance. This may also highlight the benefits of an intervention that targeted parenting-specific relapse risk factors.

Limitations and strengths

The findings of the current study should be considered in the context of several limitations. First, as our primary aim was to explore the feasibility and acceptability of DBT Skills + PT, the study was underpowered to conduct inferential analyses. Additionally, given that DBT Skills + PT is in the efficacy stage of treatment development, we chose to focus on pre-post effects among treatment completers to identify changes in secondary outcomes that may be linked to engagement with the intervention. While it is notable that many observed effect sizes in the full sample pre-post analyses were large (Appendix D; see Supplementary material), the present study did not assess or control for parents’ concurrent use of other mental health or SUD treatments. Future randomized controlled trials of DBT Skills + PT are needed to more clearly isolate and establish causal effects on parent and child outcomes.

Another limitation is the timeframe in which parents were required to have experienced a SUD: SUD remission between 12 months and 5 years. Although strategically selected, this timeframe is broad, and the remission status stage may have impacted findings. For example, parents earlier in SUD remission may have identified skills targeting addiction as being beneficial, while other parents further removed from substance use related difficulties may not feel skills for addiction were as helpful. This study also focused specifically on parents and their preschool-aged children. Thus, findings may not generalize to parents of children in different developmental stages (e.g., adolescence), who may differently benefit from other DBT (e.g., Interpersonal Effectiveness) or PT skills.

Finally, due in part to COVID-19-related restrictions, this study relied solely on parent-report, including parent-report of child behavior. A future study of DBT Skills + PT may use a multi-informant approach and more objective measures of child mental health outcomes (e.g., teacher-report).

The current study has several strengths. First, the DBT Skills + PT group represents a novel integrated intervention and meets a recognized need for programs targeting multiple interlinked domains (i.e., parent and child mental health, parenting behaviors, parenting stress, and maintained SUD remission status), relevant to families and parents in SUD remission with elevated ED. Second, the intervention is based on a strong theory of change that sees improvement in parental ED as essential to the effective parenting skills needed to foster positive child behavior, less parenting stress, and reduced risk of SUD relapse. Third, we tested DBT Skills + PT among an ethnically and socioeconomically diverse sample, with a broad range of past SUDs and current mental health diagnoses. This is notable given the high rates of diagnostic comorbidity and significantly higher rates of relapse among those with co-occurring mental health and SUDs [88]. Finally, a strength of this study is its mixed methods approach to treatment evaluation and development, which sets the stage for a future large scale effectiveness trial of DBT Skills + PT for parents in early SUD remission with elevated ED.

Conclusions

Psychotherapeutic interventions commonly target and improve only one of these interlinked domains (i.e., parent and child mental health, parenting behaviors, parenting stress), and very few integrated interventions target more than one of these domains and achieve improvement in all of them. Furthermore, interventions reporting outcomes across each domain are rarely tested in clinical samples of parents [89]. Findings from the current pilot study point to high feasibility, acceptability and engagement in DBT Skills + PT. And participating parents reported large improvements in their own mental health and emotion dysregulation, in their children’s behavior and emotion regulation, and in their parenting behaviors. These results provide promising evidence for the feasibility and acceptability of DBT Skills + PT for parents in SUD remission with elevated ED and support its preliminary efficacy in targeting the reciprocal links between parent symptoms, child symptoms, and parenting among high-risk families.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contribution

Y.E. was the principal investigator and contributed to all aspects of this study, including Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing—original draft, and Writing—review & editing. O.A.F. contributed to Writing—review & editing. I.S. contributed to Formal Analysis, Visualization, and Writing—review & editing. A.C.H. contributed to Data Curation and Writing—review & editing. A.L. contributed to Methodology and Writing—review & editing. R.C. contributed to Methodology and Writing—review & editing. K.M. contributed to Methodology and Writing—review & editing. R.E.M. contributed to Methodology and Writing—review & editing. C.M. contributed to Supervision and Writing—review & editing. M.Z. contributed to Resources, Supervision, and Writing—review & editing. All authors reviewed and approved the final manuscript.

Funding

This study was supported by funding from the National Institute of Drug Abuse’s P50 Center on Parenting and Opioids (P50 DA048756) awarded to the first author. The first author also received funding from the National Institute of Drug Abuse T32 Behavioral Sciences Training in Drug Abuse Research Fellowship at New York University (5T32 DA007233). The funders had no role in study design, data collection, analysis, and interpretation, or preparation of the manuscript.

Data availability

De-identified data from this study has been made available via the Center on Parenting and Opioids Data Repository here: https://cpo.uoregon.edu/data-repository.

Declarations

Ethics approval and consent to participate

The study was approved by the institutional review board of University of Oregon in accordance with the Declaration of Helsinki, and informed consent was obtained from all individual participants included in the study. Study protocol was registered on clinicaltrials.gov (NCT05287178) on March 18, 2022.

Consent for publication

All participants signed consent regarding publishing their data.

Competing interest

The authors declare no competing interests.