DBT for adolescent externalizing problems

What is it about?

Adolescence is an important developmental period during which youth experience key changes in their ability to regulate emotions and behavior, and engage in more reward-seeking and risk-taking behaviors than during childhood (Andrews et al., 2021; Steinberg et al., 2008). Adolescents who have difficulties with emotional and behavioral regulation are at elevated risk for externalizing problems (e.g., defiance, aggression, impulsivity, antisocial behaviors). Although externalizing problems are a common reason for psychiatric referrals (Connor et al., 2019), only a minority of youth with these difficulties receive interventions with strong research support (McCart & Sheidow, 2016). We evaluated evidence as to whether interventions based on Dialectical Behavior Therapy (DBT), a well-studied intervention designed to reduce destructive behavior by enhancing ability to regulate emotions, may reduce externalizing symptoms among adolescents. Despite DBT’s focus on changing thoughts and behaviors that precede and relate to interpersonal conflict, externalizing problems are rarely examined as a primary aim in DBT-based intervention studies. Systematic searches of peer-reviewed articles were performed on two electronic databases through February 2022. See Figure 1 for a diagram depicting the search strategy and selection procedures. Seventeen studies reporting on 16 independent samples across 5 countries were included. Each study collected data on at least one relevant outcome variable, resulting in 25 data points. In terms of covariates, we examined setting, country, study design, average age of participating adolescents, duration of intervention, number of skills group sessions, number of overall sessions, availability of phone/milieu coaching, inclusion of family members in DBT skills groups, presence of intervention modification, and reporter for the outcome variable. Results suggested that DBT-based interventions hold promise for reducing externalizing symptoms among adolescents (Hedge’s g = -.499; see Figure 2 for forest plot), and that variability in outcomes may be explained by features of the studies. Additionally, intervention duration (but not number of skills groups or overall sessions) moderated the overall effect, suggesting that a longer period of participation in treatment has a beneficial impact on adolescent externalizing symptoms regardless of the total number of skills groups or overall sessions. However, the moderating role of intervention duration approached but was no longer significant (p = .057) following removal of an outlier. No other hypothesized moderators impacted the overall effect of DBT-based interventions on externalizing symptoms.

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Why is it important?

We hope that future DBT research will continue to investigate externalizing symptom outcomes among adolescents with thoughtful inclusion of potential moderators, as well as evaluate adolescents who meet criteria for disruptive behavior disorders given DBT’s potential effectiveness for youth who might not currently receive DBT.