A Modular, Transdiagnostic Approach to Treating Severe Irritability in Children and Adolescents

A network approach to the investigation of childhood irritability: probing frustration using social stimuli

BACKGROUND

Self-regulation in early childhood develops within a social context. Variations in such development can be attributed to inter-individual behavioral differences, which can be captured both as facets of temperament and across a normal:abnormal dimensional spectrum. With increasing emphasis on irritability as a robust early-life transdiagnostic indicator of broad psychopathological risk, linkage to neural mechanisms is imperative. Currently, there is inconsistency in the identification of neural circuits that underlie irritability in children, especially in social contexts. This study aimed to address this gap by utilizing a functional magnetic resonance imaging (fMRI) paradigm to investigate pediatric anger/frustration using social stimuli.

METHODS

Seventy-three children (M = 6 years, SD = 0.565) were recruited from a larger longitudinal study on irritability development. Caregivers completed questionnaires assessing irritable temperament and clinical symptoms of irritability. Children participated in a frustration task during fMRI scanning that was designed to induce frustration through loss of a desired prize to an animated character. Data were analyzed using both general linear modeling (GLM) and independent components analysis (ICA) and examined from the temperament and clinical perspectives.

RESULTS

ICA results uncovered an overarching network structure above and beyond what was revealed by traditional GLM analyses. Results showed that greater temperamental irritability was associated with significantly diminished spatial extent of activation and low-frequency power in a network comprised of the posterior superior temporal sulcus (pSTS) and the precuneus (p < .05, FDR-corrected). However, greater severity along the spectrum of clinical expression of irritability was associated with significantly increased extent and intensity of spatial activation as well as low- and high-frequency neural signal power in the right caudate (p < .05, FDR-corrected).

CONCLUSIONS

Our findings point to specific neural circuitry underlying pediatric irritability in the context of frustration using social stimuli. Results suggest that a deliberate focus on the construction of network-based neurodevelopmental profiles and social interaction along the normal:abnormal irritability spectrum is warranted to further identify comprehensive transdiagnostic substrates of the irritability.

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

The Appa Health App for Youth Mental Health: Development and Usability Study

BACKGROUND

Demand for adolescent mental health services has surged in the aftermath of the COVID-19 pandemic, and traditional models of care entailing in-person services with licensed mental health providers are inadequate to meet demand. However, research has shown that with proper training and supervision mentors can work with youth with mental health challenges like depression and anxiety and can even support the use of evidence-based strategies like cognitive behavioral therapy (CBT). In our increasingly connected world, youth mentors can meet with young people on a web-based platform at their convenience, reducing barriers to care. Moreover, the internet has made evidence-based CBT skills for addressing depression and anxiety more accessible than ever. As such, when trained and supervised by licensed clinicians, mentors are an untapped resource to support youth with mental health challenges.

OBJECTIVE

The objective of this study was to develop and assess the feasibility and acceptability of Appa Health (Appa), an evidence-based mental health mentoring program for youth experiencing symptoms of depression and anxiety. This paper describes the development, pilot testing process, and preliminary quantitative and qualitative outcomes of Appa's 12-week smartphone app program which combines web-based near-peer mentorship with short-form TikTok-style videos teaching CBT skills created by licensed mental health professionals who are also social media influencers.

METHODS

The development and testing processes were executed through collaboration with key stakeholders, including young people and clinical and research advisory boards. In the pilot study, young people were assessed for symptoms of depression or anxiety using standard self-report clinical measures: the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 scales. Teenagers endorsing symptoms of depression or anxiety (n=14) were paired with a mentor (n=10) based on preferred characteristics such as gender, race or ethnicity, and lesbian, gay, bisexual, transgender, queer (LGBTQ) status. Quantitative survey data about the teenagers' characteristics, mental health, and feasibility and acceptability were combined with qualitative data assessing youth perspectives on the program, their mentors, and the CBT content.

RESULTS

Participants reported finding Appa helpful, with 100% (n=14) of teenagers expressing that they felt better after the 12-week program. Over 85% (n=12) said they would strongly recommend the program to a friend. The teenagers were engaged, video chatting with mentors consistently over the 12 weeks. Metrics of anxiety and depressive symptoms reduced consistently from week 1 to week 12, supporting qualitative data suggesting that mentoring combined with CBT strategies has the potential to positively impact youth mental health and warrants further study.

CONCLUSIONS

Appa Health is a novel smartphone app aiming to improve the well-being of youth and reduce anxiety and depressive symptoms through web-based mentoring and engaging CBT video content. This formative research sets the stage for a large-scale randomized controlled trial recently funded by the National Institutes of Health Small Business Innovation Research program.

Future Directions in Youth Irritability Research

Research on irritability in children and adolescents has proliferated over the last 20 years. The evidence shows the clinical and developmental significance of irritable mood and behavior in youth, and it has led to significant changes in mental health classification, diagnosis, and services. At the same time, this research (including our own) has led to relatively little new in terms of practical, empirically based guidance to improve interventions and outcomes. In this article, we briefly summarize some of these developments and current evidence-based practices. We then put forth two key substantive challenges (the "whats") for future research to address: (a) the need for more effective treatments, especially evaluating and adapting evidence-based treatments that are already well-established for problems related to irritability (e.g., cognitive-behavioral therapies for internalizing and externalizing problems); and (b) the need for a better mechanistic understanding of irritability's phenomenology (e.g., phasic vs. tonic irritability, how frustration unfolds) and putative underlying mechanisms (e.g., cognitive control, threat and reward dysfunction). Lastly, we suggest three methodological approaches (the "hows") that may expedite progress in such areas: (a) ecological momentary assessment, (b) digital health applications, and (c) leveraging existing datasets. We hope this article will be useful for students and early-career researchers interested in tackling some of these important questions to better meet the needs of severely irritable youth.

Review: Defining Positive Emotion Dysregulation: Integrating Temperamental and Clinical Perspectives

OBJECTIVE

Although emotion dysregulation has been defined as a maladaptive process of emotional experiences, there is no specific reference to the emotional valence of the dysregulation. To date, child psychiatry has focused primarily on dysregulation of negative affect. Here, we suggest that positive emotion dysregulation requires additional clinical and research attention.

METHOD

First, we present a developmental approach to the study of positive emotion regulation within a temperament framework. Second, we describe emerging research findings regarding dysregulation of positive emotion in early childhood. Third, we integrate neuroscientific approaches to positive emotion regulation and introduce a framework for future investigations and clinical applications.

RESULTS

Dysregulation in positive affect can be examined from temperamental, developmental, clinical, and neuroscientific perspectives. Both temperamental surgency, which includes positive affect, and the proposed clinical extension, excitability, are associated with increased risk of externalizing symptoms and clinical impairment in youth.

CONCLUSION

Studying the role of both temperamental surgency and clinically impairing positive affect, or excitability, in developmental psychopathology will help to elucidate the full spectrum of emotion dysregulation and to clarify the neural basis of dysregulation. A more comprehensive conceptualization of positively valanced emotion dysregulation will provide a more nuanced understanding of developmental risk and potential targets for intervention.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Systematic Review and Meta-analysis: Pharmacological and Nonpharmacological Interventions for Persistent Nonepisodic Irritability

OBJECTIVE

This meta-analysis examined the efficacy of available pharmacological and nonpharmacological interventions for irritability among youth with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), disruptive mood dysregulation disorder (DMDD), and/or severe mood dysregulation (SMD).

METHOD

Literature searches were conducted in October 2020, resulting in 564 abstracts being reviewed to identify relevant papers, with 387 articles being reviewed in full. A random effects model was used for the meta-analysis, with subgroup meta-regressions run to assess effects of study design, intervention type, medication class, and clinical population.

RESULTS

A total of 101 studies were included (80 pharmacological, 13 nonpharmacological, 8 combined). Despite high heterogeneity in effects (I2 = 94.3%), pooled posttreatment effect size for decreasing irritability was large (Hedges' g = 1.62). Large effects were found for pharmacological (g = 1.85) and nonpharmacological (g = 1.11) interventions; moderate effects were found for combined interventions relative to monotherapy interventions (g = 0.69). Antipsychotic medications provided the largest effect for reducing irritability relative to all other medication classes and nonpharmacological interventions. A large effect was found for youth with ASD (g = 1.89), whereas a medium effect was found for youth with ADHD/DMDD/DBD/SMD (g = 0.64).

CONCLUSION

This meta-analysis provides a comprehensive review of interventions targeting persistent nonepisodic irritability among youth with various psychiatric disorders. Strong evidence was found for medium-to-large effects across study design, intervention type, and clinical populations, with the largest effects for pharmacological interventions, particularly antipsychotic medications and combined pharmacological interventions, and interventions for youth with ASD.

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.

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.

Is Irritability a Top Problem in Youth Mental Health Care? A Multi-informant, Multi-method Investigation

Irritability is often described as a common problem affecting youth referred for mental health services; however, little is known about the prevalence and nature of irritability as a focus of treatment. We examined assessment data from a diverse sample of youths (N = 206; ages 7-15; 52% male, 48% female; 33% White, 27% Black, 25% Latinx) referred for outpatient treatment of emotional and behavioral concerns. Caregivers and youths completed nomothetic (standardized checklist) and idiographic (free response) measures at intake. Irritability was identified as a top problem (TP) in 58% of cases, commonly reported by caregivers (38%), youths (42%), or both (23%)-rates that were significantly greater than those of other TP domains (depression, anxiety, ADHD, conduct, and defiance). Further analyses identified clinical correlates of irritability TPs, with results supporting the incremental utility of multiple informants and methods. Findings suggest that irritability is among the most common problems for which families seek youth treatment.