Treatment of Childhood Emotion Dysregulation in Inpatient and Residential Settings

A Narrative Review of the Efficacy of Interventions for Emotional Dysregulation, and Underlying Bio-Psycho-Social Factors

In this narrative, comprehensive, and updated review of the literature, we summarize evidence about the effectiveness of interventions aimed at reducing emotion dysregulation and improving emotion regulation in children, adolescents, and adults. After introducing emotion dysregulation and emotion regulation from a theoretical standpoint, we discuss the factors commonly associated with emotion regulation, including neurobiological and neuropsychological mechanisms, and the role of childhood adverse experiences and psycho-social factors in the onset of emotion dysregulation. We then present evidence about pharmacological and non-pharmacological interventions aiming at improving emotion dysregulation and promoting emotion regulation across the lifespan. Although our review was not intended as a traditional systematic review, and the search was only restricted to systematic reviews and meta-analyses, we highlighted important implications and provided recommendations for clinical practice and future research in this field.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff.

ABSTRACT

INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required.

AIM

We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities.

METHOD

After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study.

RESULTS

After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits.

DISCUSSION

Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration.

IMPLICATIONS FOR PRACTICE

When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents

PURPOSE OF REVIEW

Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice.

RECENT FINDINGS

There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.