الفهرس 
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Abstract
Emotion dysregulation can have significant implications for overall well-being and developmental outcomes. Adolescents exhibit greater difficulties in emotion regulation when compared to adults and children. Emotion dysregulation may be indicative of psychiatric disorders and can be also typical for adolescents’ turmoil with no specified psychiatric diagnosis.
Dialectical Behavior Therapy (DBT) targets improving emotion regulation as a primary mechanism of change. One of the main goals of the Dialectical Behavior Therapy (DBT) is to cultivate conscious emotion regulation which may be later automatic response when skills are integrated into client’s behavioral paradigm.
Rathus and Miller have adapted DBT for suicidal adolescent for its strategies of keeping patients committed to treatment and for its focus on reducing both suicidal and quality of life interfering behaviors.
The aim of the present work was:
To evaluate effectiveness of Dialectical Behavior Therapy for Adolescents ”DBT-A” in Egyptian adolescent girls with emotion dysregulation recruited from adolescents’ outpatient clinics, Ain Shams University. This study also aimed to evaluate the impact of DBT-A on parenting stress of the mothers after receiving multifamily skills training group. A secondary objective was to examine the relationship between female adolescents’ emotion dysregulation and maternal emotion regulation among the study sample.
In our study we hypothesize that Dialectical Behavior Therapy for adolescents (DBT-A) would improve emotion regulation difficulties, improving distress tolerance, interpersonal effectiveness and mindfulness skills in the adolescents and their mothers. It’s also hypothesized that DBT will help reducing self-harm behaviors and suicidal ideations and behavior in the female adolescents. Teaching parents (mothers) the same skills will help in improving communication between female adolescents and their mothers thus decreasing parenting stress. Finally it’s postulated in the hypothesis that Emotion dysregulation in female adolescents is positively correlated to emotion regulation difficulties in their mothers.
Participants were female adolescents with emotion dysregulation according to Difficulties in Emotion Regulation Scale (DERS) and their mothers (Daughter/mother dyad) recruited from the adolescent psychiatric outpatient clinics, Okasha Institute of Psychiatry, Ain Shams University Hospitals, Patients with other psychiatric illnesses that may interfere with judgment (schizophrenia, any other psychotic disorder, bipolar disorder or intellectual disability) were excluded.
Twenty two female adolescents (n=22) and their mothers, (22 daughter/mother dyads) (n=44), enrolled to the study intervention, they were assigned according to the inclusion and exclusion criteria and according to their availability to attend the treatment program of comprehensive DBT for Adolescents (DBT-A) for six months.
One drop-out dyad excluded from the analysis as they couldn’t attend the treatment program due to far residence from the hospital.
All participants and their mothers signed a written informed consent to participate in the study. The study was conducted during the period from 1st of January 2022 till the end of October 2023 in Okasha Institute of Psychiatry, Ain Shams University Hospitals, the adolescent psychiatric outpatient clinics.
The study intervention was comprehensive Dialectical Behavior Therapy for Adolescents (DBT-A), a manualized, 24-week behavioral treatment, that included concurrent individual therapy once a week, phone coaching for the adolescent girls when needed, multifamily skills training group once per week for the adolescent girls with their mothers in an outpatient setting, family therapy as needed and regular team consultation meetings for the therapists. Over the 24-week group, five DBT modules of mindfulness (M), distress tolerance (DT), emotion regulation (ER) and interpersonal effectiveness (IE) and walking the middle path were covered using the translated Arabic version of DBT-A skills training handouts and worksheets.
Assessment tools performed before the intervention (for the Adolescents and their mothers) using Wechsler Intelligence Scale to exclude intellectual disability, Mini International Neuropsychiatric Interview for children and adolescents (MINI KID) for the participating adolescents to assess for the presence of current psychiatric disorders, Structured Clinical Interview for DSM-IV (SCID I) for the participating mothers to assess for the presence of current psychiatric disorders and Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II) as a screening tool for borderline personality traits and disorder and other personality traits and disorders in the adolescents and their mothers.
Assessments for outcome measures (Emotion regulation, Interpersonal difficulties inventory, Distress Tolerance Scale, Mindfulness Inventory) by the following scales respectively (Difficulties in Emotion Regulation Scale (DERS), Inventory of Interpersonal Problems-47 (IIP-47), Distress Tolerance Scale (DTS) and Freiburg Mindfulness Inventory scale (FMI)) were done for adolescents and mothers at baseline and after 6 months at end of treatment.
Additional assessments for the adolescents (Suicidal and Non-Suicidal Behavior Severity Index, Borderline symptomatology, Global Assessment of functioning, quality of life) were done for adolescents at baseline and after 6 months at end of treatment using the following scales respectively (Borderline Symptom List (BSL-23), Columbia Suicide Severity Rating Scale (C-SSRS), Global Assessment of Functioning (GAF) and World Health Organization Quality of Life-Brief (WHOQOL-BREF)). Frequency of hospitalization and Emergency department visit over the trial period were recorded and after 1 year.
Assessment for mothers’ parental stress was done at baseline and after 6 months at the end of treatment intervention using Parental Stress scale (PSS).
The collected data were presented as the mean and standard deviation (SD), median and interquartile range (IQR). Data analyzed using Mann– Whitney test and Kruskal-Wallis test, Wilcoxon signed-ranks Friedman Test, Chi-square test, McNemar test. Pearson’s correlation coefficient was calculated to estimate the degree of correlation between two quantitative variables. P value: Used to indicate level of statistical significance. Effect size using Cohen’s d to determine the practical significance of the research.
Results of this study revealed that:
The studied female adolescents with emotion dysregulation were in the age range of 15-19 years with a mean age of 17.14 ± 1.31 years. Among the current study sample of the female adolescents with emotion dysregulation, 38.1% had co-morbid psychiatric illness and 28.6% were once or twice admitted into psychiatric hospital. According to MINI KID, the most frequently detected disorder among adolescents was suicide (61.9%), then depression (28.6%), also, SUD, Mania/ Hypomania and OCD were reported in 19%, 4.8% and 4.8%, respectively. According to lifetime history 61.9% and 85.7% of the participating adolescents had history of suicide attempts and NSSI, respectively.
According to SCID I, 14.3% of the studied mothers had alcohol & SUD and 9.5% manifested mood disorders (Depression). The characteristics of the adolescents and their mothers regarding SCID II, Borderline personality disorder was prevalent among adolescents 57.1% and 14.3% of mothers.
Treatment Retention for DBT-A intervention was good with low drop-out rate (4.5%), Effect size was medium for the treatment outcomes.
As stated in the hypothesis results showed marked improvement as regards emotion regulation in the studied adolescents and their mothers, there was a statistically significant DROP in all DERS domains (non-acceptance, goals, impulse, awareness, strategies and clarity) and the total score after 6 months of DBT-A.
There was improvement in interpersonal effectiveness skills in the participating adolescents and their mothers with significant decrease in all IIPP-47 domains (interpersonal sensitivity, interpersonal ambivalence, aggression, need for social approval and lack of sociability) and the total score after 6 months of DBT-A.
As regards distress tolerance skills there was a significant decrease in all DTS domains (tolerance, appraisal, absorption and regulation) and the total score after 6 months of DBT-A indicating improvement in distress tolerance skills in the participating adolescents and their mothers.
In adolescents and their mothers, there was a statistically significant elevation in total FMI score after DBT-A indicating improvement in mindfulness skills in the participating adolescents and their mothers.
For the participating adolescents results show that BSL-23 scores (for borderline symptoms and behavior severity) were significantly decreased after DBT-A indicating improvement in Borderline symptomatology and behavior in the participating adolescents.
As regards suicidal severity index, there was a statistically significant improvement in severity of suicidal ideations, actual lethality subscale and risk stratification being less severe after DBT-A. Additionally, the frequency of true suicide attempts, suicidal behaviors with no intent, preparatory behavior, interrupted and aborted suicide attempts noticed to be significantly decreased after DBT-A.
The studied adolescents showed a statistically significant improvement in their utilization of health care facilities after DBT-A as the number of suicide attempts, para-suicidal attempts and ER visits were significantly decreased after 4, 6 months and extended 1 year after DBT-A compared to baseline. Additionally, there was a significant decrease in the number of hospital admissions after 6 months and 1 year than baseline.
There was a statistically significant increase in GAF scale score of the studied adolescents after DBT-A indicating improvement in functioning in the participating adolescents. According to WHOQOL-BREF, adolescents showed an improved quality of life after DBT-A as there was a significant increase in all domains scores (physical, psychological, social relationship, environment, overall quality of life and general health.
Finally, For the participating mothers there was a statistically significant impact of DBT-A on parental stress level as PSS was significantly decreased after DBT-A than before denoting improvement in the parental stress of the participating mothers.