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Boudjerida A, Guilé JM, Breton JJ, Benarous X, Cohen D, Labelle R. A Delphi consensus among experts on assessment and treatment of disruptive mood dysregulation disorder. Front Psychiatry 2024; 14:1166228. [PMID: 38260796 PMCID: PMC10800807 DOI: 10.3389/fpsyt.2023.1166228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Objective The aim of this study was to explore consensus among clinicians and researchers on how to assess and treat Disruptive Mood Dysregulation Disorder (DMDD). Methods The Delphi method was used to organize data collected from an initial sample of 23 child psychiatrists and psychologists. Three rounds of closed/open questions were needed to achieve the objective. Results Fifteen experts in the field completed the whole study. Finally, 122 proposals were validated and 5 were rejected. Globally, consensus was more easily reached on items regarding assessment than on those regarding treatment. Specifically, experts agreed that intensity, frequency, and impact of DMDD symptoms needed to be measured across settings, including with parents, siblings, peers, and teachers. While a low level of consensus emerged regarding optimal pharmacological treatment, the use of psychoeducation, behavior-focused therapies (e.g., dialectical behavior therapy, chain analysis, exposure, relaxation), and systemic approaches (parent management training, family therapy, parent-child interaction therapy) met with a high degree of consensus. Conclusion This study presents recommendations that reached a certain degree of consensus among researchers and clinicians regarding the assessment and treatment of youths with DMDD. These findings may be useful to clinicians working with this population and to researchers since they also highlight non-consensual areas that need to be further investigated.
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Affiliation(s)
- Assia Boudjerida
- Department of Psychology and Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal, Montréal, QC, Canada
| | - Jean-Marc Guilé
- Department Head, Child and Adolescent Psychiatry, EPSM Somme and CHU Amiens, Picardie Jules Verne University, Amiens, France
| | - Jean-Jacques Breton
- Department of Psychiatry, Rivière-des-Prairies Mental Health Hospital, Université de Montréal, Montréal, QC, Canada
| | - Xavier Benarous
- Department of Child and Adolescent Psychopathology CHU Amiens-Picardie, Amiens, France
| | - David Cohen
- Department Head, Child and Adolescent Psychiatry, Public Assistance-Hospitals of Paris, APHP, Pitié-Salpêtrière Hospital Group and National Center for Scientific Research-Joint Research Unit, Institute for Intelligent and Robotic Systems Sorbonne Université, Paris, France
| | - Réal Labelle
- Department of Psychology and Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal, Montréal, QC, Canada
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Evans SC, Shaughnessy S, Karlovich AR. Future Directions in Youth Irritability Research. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:716-734. [PMID: 37487108 DOI: 10.1080/15374416.2023.2209180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
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.
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Storebø OJ, Storm MRO, Pereira Ribeiro J, Skoog M, Groth C, Callesen HE, Schaug JP, Darling Rasmussen P, Huus CML, Zwi M, Kirubakaran R, Simonsen E, Gluud C. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev 2023; 3:CD009885. [PMID: 36971690 PMCID: PMC10042435 DOI: 10.1002/14651858.cd009885.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. OBJECTIVES To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. SELECTION CRITERIA We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. MAIN RESULTS We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. PRIMARY OUTCOMES methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). SECONDARY OUTCOMES methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.
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Affiliation(s)
- Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Maria Skoog
- Clinical Study Support, Clinical Studies Sweden - Forum South, Lund, Sweden
| | - Camilla Groth
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | | | | | | | | | - Morris Zwi
- Islington Child and Adolescent Mental Health Service, Whittington Health, London, UK
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy, Christian Medical College, Vellore, India
| | - Erik Simonsen
- Research Unit, Mental Health services, Region Zealand Psychiatry, Roskilde, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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4
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Breaux R, Baweja R, Eadeh HM, Shroff DM, Cash AR, Swanson CS, Knehans A, Waxmonsky JG. Systematic Review and Meta-analysis: Pharmacological and Nonpharmacological Interventions for Persistent Nonepisodic Irritability. J Am Acad Child Adolesc Psychiatry 2023; 62:318-334. [PMID: 35714838 DOI: 10.1016/j.jaac.2022.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 04/11/2022] [Accepted: 06/07/2022] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Rosanna Breaux
- Virginia Polytechnic Institute and State University, Blacksburg.
| | - Raman Baweja
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Annah R Cash
- Virginia Polytechnic Institute and State University, Blacksburg
| | | | - Amy Knehans
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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5
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Carlson GA, Singh MK, Amaya-Jackson L, Benton TD, Althoff RR, Bellonci C, Bostic JQ, Chua JD, Findling RL, Galanter CA, Gerson RS, Sorter MT, Stringaris A, Waxmonsky JG, McClellan JM. Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them. J Am Acad Child Adolesc Psychiatry 2023; 62:135-150. [PMID: 35358662 DOI: 10.1016/j.jaac.2022.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Gabrielle A Carlson
- Renaissance School of Medicine at Stony Brook University, Putnam Hall, South Campus, Stony Brook, New York.
| | | | | | - Tami D Benton
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Jeff Q Bostic
- MedStar Georgetown University Hospital, Washington, DC
| | - Jaclyn Datar Chua
- Perelman School of Medicine, University of Pennsylvania, Philadelphia; University of Pennsylvania, Philadelphia
| | | | - Cathryn A Galanter
- SUNY Downstate, Brooklyn, New York; Kings County Hospital Center, Brooklyn, New York
| | | | - Michael T Sorter
- Cincinnati Children's Hospital and the University of Cincinnati, Ohio
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6
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Baweja R, Waxmonsky JG. Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:479-498. [PMID: 35697397 DOI: 10.1016/j.chc.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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7
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Ametti MR, Crehan ET, O’Loughlin K, Schreck MC, Dube SL, Potter AS, Sigmon SC, Althoff RR. Frustration, Cognition, and Psychophysiology in Dysregulated Children: A Research Domain Criteria Approach. J Am Acad Child Adolesc Psychiatry 2022; 61:796-808.e2. [PMID: 35074486 PMCID: PMC9275749 DOI: 10.1016/j.jaac.2021.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/30/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Dysregulated children experience significant impairment in regulating their affect, behavior, and cognitions and are at risk for numerous adverse sequelae. The unclear phenomenology of their symptoms presents a barrier to evidence-based diagnosis and treatment. METHOD The cognitive, behavioral, and psychophysiological mechanisms of dysregulation were examined in a mixed clinical and community sample of 294 children ages 7-17 using the Research Domain Criteria constructs of cognitive control and frustrative nonreward. RESULTS Results showed that caregivers of dysregulated children viewed them as having many more problems with everyday executive function than children with moderate or low levels of psychiatric symptoms; however, during standardized assessments of more complex cognitive control tasks, performance of dysregulated children differed only from children with low symptoms on tests of cognitive flexibility. In addition, when frustrated, dysregulated children performed more poorly on the Go/No-Go Task and demonstrated less autonomic flexibility as indexed by low respiratory sinus arrhythmia and pre-ejection period scores. CONCLUSION The findings of this study suggest that autonomic inflexibility and impaired cognitive function in the context of frustration may be mechanisms underlying childhood dysregulation.
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8
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Lee KS, Xiao J, Luo J, Leibenluft E, Liew Z, Tseng WL. Characterizing the Neural Correlates of Response Inhibition and Error Processing in Children With Symptoms of Irritability and/or Attention-Deficit/Hyperactivity Disorder in the ABCD Study®. Front Psychiatry 2022; 13:803891. [PMID: 35308882 PMCID: PMC8931695 DOI: 10.3389/fpsyt.2022.803891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD), characterized by symptoms of inattention and/or hyperactivity and impulsivity, is a neurodevelopmental disorder associated with executive dysfunctions, including response inhibition and error processing. Research has documented a common co-occurrence between ADHD and pediatric irritability. The latter is more characterized by affective symptoms, specifically frequent temper outbursts and low frustration tolerance relative to typically developing peers. Shared and non-shared neural correlates of youths with varied profiles of ADHD and irritability symptoms during childhood remain largely unknown. This study first classified a large sample of youths in the Adolescent Brain Cognitive Development (ABCD) study at baseline into distinct phenotypic groups based on ADHD and irritability symptoms (N = 11,748), and then examined shared and non-shared neural correlates of response inhibition and error processing during the Stop Signal Task in a subset of sample with quality neuroimaging data (N = 5,948). Latent class analysis (LCA) revealed four phenotypic groups, i.e., high ADHD with co-occurring irritability symptoms (n = 787, 6.7%), moderate ADHD with low irritability symptoms (n = 901, 7.7%), high irritability with no ADHD symptoms (n = 279, 2.4%), and typically developing peers with low ADHD and low irritability symptoms (n = 9,781, 83.3%). Latent variable modeling revealed group differences in the neural coactivation network supporting response inhibition in the fronto-parietal regions, but limited differences in error processing across frontal and posterior regions. These neural differences were marked by decreased coactivation in the irritability only group relative to youths with ADHD and co-occurring irritability symptoms and typically developing peers during response inhibition. Together, this study provided initial evidence for differential neural mechanisms of response inhibition associated with ADHD, irritability, and their co-occurrence. Precision medicine attending to individual differences in ADHD and irritability symptoms and the underlying mechanisms are warranted when treating affected children and families.
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Affiliation(s)
- Ka Shu Lee
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, United States
| | - Jingyuan Xiao
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, United States
- Yale Center for Perinatal, Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, United States
| | - Jiajun Luo
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, United States
- Yale Center for Perinatal, Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, United States
- Institute for Population and Precision Health, The University of Chicago, Chicago, IL, United States
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Zeyan Liew
- Yale Center for Perinatal, Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, United States
| | - Wan-Ling Tseng
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, United States
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9
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Sorter M, Chua J, Lamy M, Barzman D, Ryes L, Shekhtman JA. Management of Emotion Dysregulation and Outbursts in Children and Adolescents. Curr Psychiatry Rep 2022; 24:213-226. [PMID: 35316849 DOI: 10.1007/s11920-022-01325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Michael Sorter
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Jaclyn Chua
- Children's Hospital of Philadelphia, Philadelphia, USA
| | - Martine Lamy
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Drew Barzman
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Louis Ryes
- Xavier University, Cincinnati, USA.,University of Kentucky College of Medicine, Lexington, USA
| | - Joshua Abraham Shekhtman
- The Ohio State University, Columbus, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
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10
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Mulraney M, Sciberras E, Payne JM, De Luca C, Mills J, Tennant M, Coghill D. Collaborative and Proactive Solutions compared with usual care to treat irritability in children and adolescents: a pilot randomized controlled trial. CLIN PSYCHOL-UK 2022. [DOI: 10.1080/13284207.2022.2041983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Melissa Mulraney
- Institute for Social Neuroscience, ISN Psychology, Ivanhoe, Australia
- Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Emma Sciberras
- Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Parkville, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Jonathan M Payne
- Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Mental Health, The Royal Children’s Hospital, Parkville, Australia
| | - Cinzia De Luca
- Brain and Mind, Murdoch Children’s Research Institute, Parkville, Australia
- Children’s Cancer Centre, The Royal Children’s Hospital, Parkville, Australia
| | - John Mills
- Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Parkville, Australia
| | - Michelle Tennant
- School of Psychology, Deakin University, Geelong, Australia
- Brain and Mind, Murdoch Children’s Research Institute, Parkville, Australia
| | - David Coghill
- Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Mental Health, The Royal Children’s Hospital, Parkville, Australia
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11
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Breaux R, Dunn NC, Swanson CS, Larkin E, Waxmonsky J, Baweja R. A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Front Psychiatry 2022; 13:794044. [PMID: 35237188 PMCID: PMC8882725 DOI: 10.3389/fpsyt.2022.794044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/24/2022] [Indexed: 12/03/2022] Open
Abstract
Approximately a third of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) experience significant irritability; despite this, no study has reviewed whether interventions for youth with ADHD can improve irritability. This mini review sought to address this gap in the literature by discussing existing pharmacological and psychosocial interventions for irritability among children and adolescents with ADHD. A literature search was conducted in April 2021, with a total of 12 intervention articles identified (six pharmacological, one psychosocial, five combined). Studies were excluded if they did not involve an intervention, a measure of irritability, or the population was not youth with ADHD. Of these articles, two were with an ADHD only sample; seven included ADHD with comorbid disruptive behavior, disruptive mood dysregulation disorder (DMDD), or severe mood dysregulation (SMD); and three included ADHD with comorbid autism spectrum disorder (ASD). Findings suggest that central nervous system stimulants used alone or in combination with behavior therapy are effective at reducing irritability in youth with ADHD only or comorbid ADHD and DMDD/SMD. Less evidence was found for the efficacy of guanfacine and atomoxetine for youth with ADHD only or comorbid ADHD and ASD. Parent training alone or in combination with atomoxetine was found to be effective at reducing irritability in youth with comorbid ADHD and ASD. Future research assessing the efficacy of other psychosocial interventions, particularly cognitive behavioral therapy is necessary, as are randomized trials assessing intervention sequencing and intensity among youth with ADHD. Researchers are advised to utilize well-validated measures of irritability in future research.
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Affiliation(s)
- Rosanna Breaux
- Coping Skills and Learning to Manage Emotions Readily (CALMER) Lab, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Nicholas C Dunn
- Coping Skills and Learning to Manage Emotions Readily (CALMER) Lab, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Courtney S Swanson
- Coping Skills and Learning to Manage Emotions Readily (CALMER) Lab, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Emma Larkin
- Coping Skills and Learning to Manage Emotions Readily (CALMER) Lab, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - James Waxmonsky
- Attention and Behavior Clinic, Department of Psychiatry and Behavioral Health, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Raman Baweja
- Attention and Behavior Clinic, Department of Psychiatry and Behavioral Health, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
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12
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Groves NB, Chan ESM, Marsh CL, Gaye F, Jaisle EM, Kofler MJ. Does central executive training and/or inhibitory control training improve emotion regulation for children with attention-deficit/hyperactivity disorder? A randomized controlled trial. Front Psychiatry 2022; 13:1034722. [PMID: 36561637 PMCID: PMC9763728 DOI: 10.3389/fpsyt.2022.1034722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Approximately 48-54% of children with attention-deficit/hyperactivity disorder (ADHD) have impairing difficulties with emotion regulation, and these difficulties are not ameliorated by first-line ADHD treatments. Working memory and inhibitory control represent promising intervention targets given their functional, if not causal, links with ADHD-related emotion dysregulation. METHODS This preregistered randomized controlled trial tested whether two digital therapeutic training protocols that have been previously shown to improve working memory (Central Executive Training [CET]) and inhibitory control (Inhibitory Control Training [ICT]) can improve emotion regulation in a sample of 94 children with ADHD aged 8-13 years (M = 10.22, SD = 1.43; 76% White/non-Hispanic; 29 girls). RESULTS Results of Bayesian mixed model ANOVAs indicated both treatment groups demonstrated significant decreases in emotion dysregulation relative to pre-treatment at immediate post-treatment (parent report; d = 1.25, BF10 = 8.04 × 1013, p < 0.001), at 1-2 months after completing treatment (teacher report; d = 0.99, BF10 = 1.22 × 106, p < 0.001), and at 2-4-months follow-up (parent report; d = 1.22, BF10 = 1.15 × 1014, p < 0.001). Contrary to our hypotheses, the CET and ICT groups demonstrated equivalent reductions in emotion dysregulation and maintenance of effects. Exploratory analyses revealed that results were robust to control for informant expectancies, ADHD medication status/changes, in-person vs. at-home treatment, child age, and time from treatment completion to post-treatment ratings. DISCUSSION To determine whether working memory and inhibitory control are causally linked with ADHD-related emotion dysregulation, future studies should include active control conditions that do not train executive functions prior to making decisions about the clinical utility of CET/ICT for the treatment of emotion dysregulation in ADHD. CLINICAL TRIAL REGISTRATION [https://clinicaltrials.gov/], identifier [NCT03324464].
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Affiliation(s)
- Nicole B Groves
- Department of Psychology, Florida State University, Tallahassee, FL, United States
| | - Elizabeth S M Chan
- Department of Psychology, Florida State University, Tallahassee, FL, United States
| | - Carolyn L Marsh
- Department of Psychology, Florida State University, Tallahassee, FL, United States
| | - Fatou Gaye
- Department of Psychology, Florida State University, Tallahassee, FL, United States
| | - Emma M Jaisle
- Department of Psychology, Florida International University, Miami, FL, United States
| | - Michael J Kofler
- Department of Psychology, Florida State University, Tallahassee, FL, United States
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13
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Cardinale EM, Freitag GF, Brotman MA, Pine DS, Leibenluft E, Kircanski K. Phasic Versus Tonic Irritability: Differential Associations With Attention-Deficit/Hyperactivity Disorder Symptoms. J Am Acad Child Adolesc Psychiatry 2021; 60:1513-1523. [PMID: 33440203 PMCID: PMC9073575 DOI: 10.1016/j.jaac.2020.11.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/18/2020] [Accepted: 01/04/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Irritability is a multifaceted construct in pediatric psychopathology. It has been conceptualized as having a phasic dimension and a tonic dimension. Disruptive mood dysregulation disorder is defined by the presence of both dimensions. Severe irritability, or disruptive mood dysregulation disorder, is highly comorbid with attention-deficit/hyperactivity disorder (ADHD). However, it is unknown whether the presence of ADHD modulates the expression of phasic and tonic irritability. METHOD A data-driven, latent variable approach was used to examine irritability and ADHD symptoms in a transdiagnostic pediatric sample (N = 489) with primary disruptive mood dysregulation disorder, ADHD, subclinical irritability symptoms, or no diagnosis. Using latent profile analyses, we identified 4 classes: high levels of both irritability and ADHD symptoms, high levels of irritability and moderate levels of ADHD symptoms, moderate levels of irritability and high levels of ADHD symptoms, and low levels of both irritability and ADHD symptoms. Confirmatory factor analysis operationalized phasic irritability and tonic irritability. RESULTS As expected, the 2 latent classes characterized by high overall irritability exhibited the highest levels of both phasic and tonic irritability. However, between these 2 high irritability classes, highly comorbid ADHD symptoms were associated with significantly greater phasic irritability than were moderately comorbid ADHD symptoms. In contrast, the 2 high irritability groups did not differ on levels of tonic irritability. CONCLUSION These findings suggest that phasic, but not tonic, irritability has a significant association with ADHD symptoms and that phasic and tonic might be distinct, though highly related, irritability dimensions. Future research should investigate potential mechanisms underlying this differential association.
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14
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Executive Functioning and Emotion Regulation in Children with and without ADHD. Res Child Adolesc Psychopathol 2021; 50:721-735. [PMID: 34762251 DOI: 10.1007/s10802-021-00883-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
Difficulties with emotion regulation affect the majority of youth with attention-deficit/hyperactivity disorder (ADHD) and predict greater functional impairment than ADHD symptoms alone. Deficits in executive functioning are also present for most children with ADHD, and have been linked with emotion regulation difficulties in both clinical and neurotypical populations throughout development. The current study was the first to assess all three core executive functions (working memory, inhibitory control, set shifting) simultaneously in a clinically-diverse sample of children with and without ADHD and common comorbidities and investigate the extent to which they uniquely predict emotion dysregulation. A sample of 151 children ages 8-13 years (M = 10.36, SD = 1.52; 52 girls; 70.2% White/Non-Hispanic) were assessed using a criterion battery of executive functioning tasks, teacher-reported ADHD symptoms, and parent-reported emotion regulation. Results of the bias-corrected, bootstrapped conditional effects path model revealed that better-developed working memory predicted better emotion regulation (β = 0.23) and fewer ADHD symptoms (β = -0.21 to -0.37), that ADHD symptoms (β = -0.18 to -0.20) independently predicted emotion dysregulation, and that working memory exerted indirect effects on emotion regulation through both inattention and hyperactivity/impulsivity (β = 0.04-0.07). Sensitivity analyses indicated that these effects were generally robust to control for age, sex, executive function interrelations, and inclusion/exclusion of children with co-occurring ASD. These findings underscore the importance of working memory (relative to inhibitory control and set shifting) and its relations with ADHD symptoms for understanding children's emotion regulation skills, and may help explain the limited efficacy of first-line ADHD treatments, which do not target working memory, for improving emotion regulation skills.
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15
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Groves NB, Kofler MJ, Wells EL, Day TN, Chan ESM. An Examination of Relations Among Working Memory, ADHD Symptoms, and Emotion Regulation. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2021; 48:525-537. [PMID: 31900835 DOI: 10.1007/s10802-019-00612-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Emotion regulation difficulties are present in many, if not most, children with attention-deficit/hyperactivity disorder (ADHD) and confer risk for a host of adverse outcomes. Little is known, however, regarding the neurocognitive and behavioral mechanisms that underlie these difficulties. A well-characterized, clinically evaluated sample of 145 children ages 8-13 years (M = 10.33, SD = 1.47; 55 girls; 69% White/non-Hispanic) were administered multiple, counterbalanced working memory tests and assessed for emotion dysregulation and ADHD symptoms via multiple-informant reports. Bias-corrected, bootstrapped conditional effects modeling indicated that underdeveloped working memory exerted significant direct effects on emotion regulation in all tested models as well as indirect effects on emotion regulation via parent-reported hyperactive/impulsive symptoms (95% CIs excluded zero). Interestingly, hyperactive/impulsive symptoms also predicted emotion dysregulation when controlling for the influence of working memory. Inattention failed to predict emotion regulation difficulties in all tested models (all 95% CIs included zero). This pattern of results replicated across parent and teacher models and were robust to control for mono-informant bias, age, and gender. These findings suggest that emotion dysregulation in ADHD reflects, in part, both a direct outcome of underdeveloped working memory and an affective outcome of hyperactive and/or impulsive symptomatology, both attributable to and independent of the role of underlying working memory deficits.
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Affiliation(s)
- Nicole B Groves
- Department of Psychology, Florida State University, 1107 W. Call Street, Tallahassee, FL, 32306-4301, USA
| | - Michael J Kofler
- Department of Psychology, Florida State University, 1107 W. Call Street, Tallahassee, FL, 32306-4301, USA.
| | - Erica L Wells
- Department of Psychology, Florida State University, 1107 W. Call Street, Tallahassee, FL, 32306-4301, USA
| | - Taylor N Day
- Department of Psychology, Florida State University, 1107 W. Call Street, Tallahassee, FL, 32306-4301, USA
| | - Elizabeth S M Chan
- Department of Psychology, Florida State University, 1107 W. Call Street, Tallahassee, FL, 32306-4301, USA
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Waxmonsky JG, Baweja R, Bansal PS, Waschbusch DA. A Review of the Evidence Base for Psychosocial Interventions for the Treatment of Emotion Dysregulation in Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2021; 30:573-594. [PMID: 34053687 DOI: 10.1016/j.chc.2021.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Many children with a range of psychiatric diagnoses manifest impaired levels of emotion dysregulation (ED). Over the past decade, there has been increasing examination of psychosocial interventions for ED. We found preliminary evidence of positive effects for a wide range of psychosocial treatments that were associated with improvements in emotion recognition, emotional reactivity, and emotion regulation. More studies are needed because results are limited by the small number of controlled trials, heavy reliance on parent ratings, and heterogeneity of the samples.
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Affiliation(s)
- James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033, USA.
| | - Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033, USA
| | - Pevitr S Bansal
- Department of Psychology in the College of Arts and Sciences at the University of Kentucky, 171 Funkhouser Drive, Lexington, KY, USA
| | - Daniel A Waschbusch
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033, USA
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17
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Brandt L, Levin FR, Kraigher D. Impulsive Personality Traits Mediate the Relationship Between Attention-Deficit/Hyperactivity Disorder Symptoms and Psychiatric Comorbidity among Patients with Severe Alcohol Use Disorder. J Dual Diagn 2021; 17:193-206. [PMID: 34313557 PMCID: PMC8452140 DOI: 10.1080/15504263.2021.1944711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is an established risk factor for developing alcohol use disorder (AUD), and AUD-ADHD comorbidity is associated with additional psychiatric diagnoses. Several lines of evidence support the role of impulsivity as a pathway of these relationships; however, impulsivity is not a unitary construct. Thus, we sought to explore whether separate aspects of impulsivity may explain the relationship between ADHD symptoms and psychiatric comorbidity among inpatients (N = 136) with AUD. Methods: We assessed ADHD symptoms (childhood ADHD [Wender Utah Rating Scale], adult ADHD [Adult ADHD self-report scale]), health-related quality of life (HRQL; EQ-5D-5L), psychiatric comorbidity (Mini International Neuropsychiatric Interview), and impulsive personality traits (Urgency, Premeditation, Perseverance, Sensation seeking [UPPS] scale). Results: 19% of patients screened positive in the retrospective assessment of childhood ADHD, and 17% for adult ADHD. Participants reported moderate levels of problem severity in the HRQL dimensions, and 65% had ≥1 current psychiatric disorders other than AUD and ADHD. Multiple mediation indicated that there was a significant direct effect of childhood ADHD symptoms on psychiatric comorbidity (β = 0.224, 95% CI [0.080, 1.114]), and indirect effects of both reacting impetuously when experiencing negative emotions (negative urgency; β = 0.999, 95% CI [0.043, 0.461]) and the tendency to not finish tasks (lack of perseverance; β = 0.075, 95% CI [0.002, 0.297]). Conclusions: The subcomponents of impulsivity to react rashly when experiencing negative emotions and the tendency to not persist in activities seem to contribute to the relationship between ADHD symptoms (particularly those in childhood) and psychiatric comorbidity among patients with severe AUD.
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Affiliation(s)
- Laura Brandt
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA.,Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA.,Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
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Abstract
Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.
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19
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Baweja R, Waschbusch DA, Pelham WE, Pelham WE, Waxmonsky JG. The Impact of Persistent Irritability on the Medication Treatment of Paediatric Attention Deficit Hyperactivity Disorder. Front Psychiatry 2021; 12:699687. [PMID: 34366928 PMCID: PMC8333707 DOI: 10.3389/fpsyt.2021.699687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
This study compares the efficacy and tolerability of central nervous system (CNS) stimulants in children with attention deficit hyperactivity disorder (ADHD) with and without prominent irritability (IRR) over the course of 30 months. This is a secondary analysis of a study examining growth patterns in medication naïve children with ADHD subsequently treated with CNS stimulants (predominantly OROS-Methylphenidate, up to 54 mg per day) for 30 months. Participants had to meet full diagnostic criteria for ADHD and been treated with CNS stimulants for under 30 days. Children were classified as IRR if they were rated as pretty much or very much on either of the "often angry" or easily annoyed" items plus "lose temper," items of the Disruptive Behavior Disorders Rating Scale (DBDRS). Structured ratings of ADHD symptoms, impairment, side effects, and symptoms of oppositional defiant disorder (ODD) were collected every 2-12 weeks for the duration of the study. Medication use was measured by pill count and parent report. The IRR group comprised 28% of all participants. The IRR group had significantly higher levels of ADHD and ODD symptoms, impairment, and side effects ratings at baseline. In the IRR group, ODD symptoms, emotional lability, and impairment significantly decreased for participants with higher medication use. Total side effects increased for non-IRR participants with higher medication use. Emotional side effects decreased for IRR participants with higher medication use. Central nervous system stimulants were a tolerable and efficacious treatment in treatment naïve youth with ADHD with irritability. Clinical Trials Registration: NCT01109849.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, Hershey, PA, United States
| | - Daniel A Waschbusch
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, Hershey, PA, United States
| | - William E Pelham
- Center of Human Development, University of California, San Diego, San Diego, CA, United States
| | - William E Pelham
- Center for Children and Families Florida International University, Miami, FL, United States
| | - James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, Hershey, PA, United States
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20
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Monopoli WJ, Evans SW, Benson K, Allan NP, Owens JS, DuPaul GJ, Bunford N. Assessment of a conceptually informed measure of emotion dysregulation: Evidence of construct validity vis a vis impulsivity and internalizing symptoms in adolescents with ADHD. Int J Methods Psychiatr Res 2020; 29:1-14. [PMID: 32898309 PMCID: PMC7723178 DOI: 10.1002/mpr.1826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 03/06/2020] [Accepted: 03/29/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Despite advances in understanding associations among attention-deficit hyperactivity disorder (ADHD), emotion dysregulation (ED), and related outcomes, there is incongruity between ADHD-relevant conceptualizations of ED and available measures of ED. To assess the psychometric properties of a parent-report questionnaire of ED conceptualized as deficits in the ability to modulate the (a) speed/degree of emotion escalation; (b) expression intensity; and (c) speed/degree of de-escalation. METHODS Participants were 209 adolescents with ADHD (78% male; 13.5-17.8 years old [M = 15.2 SD = 0.91]). Questionnaire items were selected from parent-report scales of ED and oppositional defiant disorder and subjected to exploratory factor analysis (EFA) and validity analyses. RESULTS The EFA revealed two factors, with speed/degree of escalation combined with intensity as factor one, and speed/degree of de-escalation as factor two. Factor one scores were related to ADHD impulsivity symptoms but not to anxiety and depression symptoms and they remained predictors of impulsivity even in the presence of self-report ED, evincing convergent, discriminant, and incremental validity. Factor two scores were related to anxiety and depression but not impulsivity, evincing convergent and discriminant validity. CONCLUSION These results inform our understanding of ADHD-relevant ED in adolescence and offer avenues for future research in measurement development, as well as for understanding ED and ADHD-related impairment.
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Affiliation(s)
- W John Monopoli
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Steven W Evans
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | - Kari Benson
- Department of Psychology, Ohio University, Athens, Ohio, USA
| | | | | | - George J DuPaul
- Department of Education and Human Services, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Nóra Bunford
- 'Lendület' Developmental and Translational Neuroscience Research Group, Institute of Cognitive Neuroscience and Psychology, Research Centre for Natural Sciences, Budapest, Hungary
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21
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Little K, Raiker J, Coxe S, Campez M, Jusko M, Smith J, Gnagy E, Greiner A, Villodas M, Coles E, Pelham WE. A Preliminary Evaluation of the Utility of Sluggish Cognitive Tempo Symptoms in Predicting Behavioral Treatment Response in Children with Behavioral Difficulties. Psychol Rep 2020; 124:2063-2091. [PMID: 32921265 DOI: 10.1177/0033294120957239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Interest in symptoms of sluggish cognitive tempo (SCT) has led to a number of studies evaluating how these symptoms respond to treatment commonly utilized in youths with symptoms of ADHD. No study to date, however, has examined the extent to which symptoms of SCT predict behavioral treatment response in youths across multiple domains of functioning. The current preliminary investigation integrates a number of methodological (e.g., direct observations) and analytic (e.g., Poisson regression) refinements to evaluate the extent to which symptoms of SCT predict treatment responses across multiple domains including behavioral (e.g., interruptions, rule violations), social (e.g., social skills, negative verbalizations), and severe behavioral difficulties (e.g., intentional aggression) above and beyond other demographic characteristics (e.g., symptom severity, Full Scale Intelligence Quotient [FSIQ]). A relatively small sample of 37 children, aged six to 12 years (M = 8.03, SD = 1.83, 35 males: 2 females) attending an eight week multi-component intensive behavioral treatment program for youths with behavioral difficulties participated in the current study. Baseline parental perceptions of SCT were collected prior to the initiation of treatment. Results from this preliminary investigation revealed that pre-treatment SCT symptoms only predicted a less robust treatment response to time out which was associated also with parent's perceptions of underlying working memory problems. Results revealed also that pre-treatment SCT symptoms failed to predict paraprofessional counselor's and teacher's improvement ratings of both rule following and social skills following treatment. Notably, other potential predictors (e.g., symptom severity, FSIQ) also largely failed to predict behavioral treatment response.
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Affiliation(s)
- Kelcey Little
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Joseph Raiker
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Stefany Coxe
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Mileini Campez
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Morgan Jusko
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Jessica Smith
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Elizabeth Gnagy
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Andrew Greiner
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Miguel Villodas
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - Erika Coles
- Center for Children and Families, Florida International University, Miami, FL, USA
| | - William E Pelham
- Center for Children and Families, Florida International University, Miami, FL, USA
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Vacher C, Goujon A, Romo L, Purper-Ouakil D. Efficacy of psychosocial interventions for children with ADHD and emotion dysregulation: a systematic review. Psychiatry Res 2020; 291:113151. [PMID: 32619822 DOI: 10.1016/j.psychres.2020.113151] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 03/09/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022]
Abstract
Attention-Deficit Hyperactivity Disorder (ADHD) is frequently associated with emotion dysregulation (ED) that is characterized by excessive and inappropriate emotional reactions. Children with ADHD and ED present significant social, academic and family functioning impairments. These findings indicate that ED should be regularly monitored in children with ADHD and should be managed with targeted therapeutic interventions. However, few studies have evaluated the efficacy of psychosocial interventions to manage ED in children with ADHD. The aim of this systematic review was to assess the effects of psychosocial interventions for children with ADHD and ED, particularly their benefits and limitations. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) model. A systematic literature search of different databases in February 2018 allowed the identification of five randomized controlled trials, one quasi-experimental study, and four open-label uncontrolled studies. Analysis of the results reported in these studies suggested that psychosocial interventions can improve severe irritability and aggressive behavior in children with ADHD and ED. However, the short trial duration, the lack of follow-up and of control group in several studies, and the heterogeneity of the outcome measures affected the result interpretation. Future studies should use standardized measures of ED and larger samples.
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Affiliation(s)
- Cécile Vacher
- Centre Hospitalo-Universitaire de Montpellier, Service Médecine Psychologique de l'Enfant et de l'Adolescent, Montpellier, Hérault, France; CLIPSYD EA-4430, UFR Sciences Psychologiques et Sciences de l'Education, Université de Nanterre, Nanterre, Hauts de Seine, France.
| | - Allison Goujon
- Centre Hospitalo-Universitaire de Montpellier, Service Médecine Psychologique de l'Enfant et de l'Adolescent, Montpellier, Hérault, France
| | - Lucia Romo
- CLIPSYD EA-4430, UFR Sciences Psychologiques et Sciences de l'Education, Université de Nanterre, Nanterre, Hauts de Seine, France; CMME, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences; INSERM UMR1266 Institute of Psychiatry and Neuroscience of Paris
| | - Diane Purper-Ouakil
- Centre Hospitalo-Universitaire de Montpellier, Service Médecine Psychologique de l'Enfant et de l'Adolescent, Montpellier, Hérault, France; INSERM U1018 CESP/Psychiatry, development and trajectories, Montpellier
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Mayes SD, Waxmonsky JG, Baweja R, Mattison RE, Memon H, Klein M, Hameed U, Waschbusch D. Symptom scores and medication treatment patterns in children with ADHD versus autism. Psychiatry Res 2020; 288:112937. [PMID: 32315876 DOI: 10.1016/j.psychres.2020.112937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/22/2020] [Indexed: 01/27/2023]
Abstract
Most children with autism have ADHD, and children with ADHD-Combined and children with autism have high rates of irritable, oppositional, and aggressive behavior. Despite similar symptoms, prescribing practices may differ between autism and ADHD, which has not been examined in a single study. 1407 children with autism and 1036 with ADHD without autism, 2-17 years, were compared with 186 typical peers. Symptom scores were maternal Pediatric Behavior Scale ratings in eight areas (ADHD, oppositional/aggressive, irritable/angry, anxious, depressed, and social, writing, and learning problems). Psychotropics were prescribed to 38.0% with ADHD-Combined, 33.3% with autism, and 20.2% with ADHD-Inattentive, most often an ADHD medication (22.1% stimulant, 2.3% atomoxetine), antipsychotic (7.8%), SSRI (5.5%), and alpha agonist (4.9%). ADHD medications were more often prescribed than other medications in all diagnostic groups. Compared to autism, children with ADHD-Combined were more likely to be prescribed an ADHD medication, whereas antipsychotics and SSRIs were more likely to be prescribed in autism than in ADHD-Combined. Children with ADHD-Inattentive were least impaired and least likely to be medicated. More severely impaired children were more often medicated regardless of diagnosis. Symptom scores were far worse for treated and untreated children with ADHD and with autism than for typical peers.
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Affiliation(s)
- Susan D Mayes
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States.
| | - James G Waxmonsky
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Raman Baweja
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Richard E Mattison
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Hasan Memon
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Melanie Klein
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Usman Hameed
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
| | - Daniel Waschbusch
- Department of Psychiatry, Penn State College of Medicine, Hershey Medical Center, 500 University Dr., Hershey, PA, United States
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Hendrickson B, Girma M, Miller L. Review of the clinical approach to the treatment of disruptive mood dysregulation disorder. Int Rev Psychiatry 2020; 32:202-211. [PMID: 31775528 DOI: 10.1080/09540261.2019.1688260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Though a decade of research led to the creation of disruptive mood dysregulation disorder (DMDD), it was not until the 2013 publication of the DSM-5 that DMDD became an official diagnosis. The conception of DMDD was largely due to increasing rates of paediatric bipolar disorder (PBD) diagnoses, which significantly impacted treatment for these youth. The core symptoms of DMDD include persistent irritability and recurrent outbursts; the absence of a previous diagnostic category for youth experiencing these symptoms may have led to the over diagnosis of PBD. Due to the chronicity of symptoms, these youth are impaired in multiple areas of functioning. This article will present background information about DMDD, discuss clinical assessment strategies including scales for measuring irritability and aggression, and review pharmacologic and psychosocial treatments for youth with DMDD and clinical phenotypes similar to DMDD.
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Affiliation(s)
- Brian Hendrickson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahlet Girma
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leslie Miller
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Carlson GA, Chua J, Pan K, Hasan T, Bied A, Martin A, Klein DN. Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study. J Am Acad Child Adolesc Psychiatry 2020; 59:632-641.e4. [PMID: 31381991 DOI: 10.1016/j.jaac.2019.07.940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued. METHOD We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use. RESULTS Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002). CONCLUSION In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.
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Affiliation(s)
| | - Jaclyn Chua
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Katherine Pan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Tahsin Hasan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Adam Bied
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Andrés Martin
- Child Study Center, Yale School of Medicine, New Haven, CT
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Wells EL, Groves NB, Day TN, Harmon SL, Soto EF, Miller CE, Kofler MJ. Evidence against emotion inference deficits in children with ADHD. Emotion 2020; 21:665-677. [PMID: 32191096 DOI: 10.1037/emo0000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Inconsistent evidence suggests that pediatric attention deficit/hyperactivity disorder (ADHD) may be associated with impairments in the ability to use context clues to infer the emotion states of others. However, the evidence base for these impairments is comprised of data from laboratory-based tests of emotion inference that may be confounded by demands on nonaffective cognitive processes that have been linked with ADHD. The current study builds on our previous study of facial affect recognition to address this limitation and investigate a potential mechanism underlying children's ability to infer emotion state from context clues. To do so, we used a fully crossed, counterbalanced experimental design that systematically manipulated emotion inference and working memory demands in 77 carefully phenotyped children ages 8-13 (Mage = 10.46, SD = 1.54; 66% Caucasian/Non-Hispanic; 42% female) with ADHD (n = 42) and without ADHD (n = 35). Results of Bayesian mixed-model ANOVAs indicated that using context clues to infer the emotion state of others competed for neurocognitive resources with the processes involved in rehearsing/maintaining information within working memory (BF₁₀ = 1.57 × 10¹⁹, d = 0.72). Importantly, there was significant evidence against the critical Group × Condition interaction for response times (BF₀₁ = 4.93), and no significant evidence for this interaction for accuracy (BF₀₁ = 2.40). In other words, children with ADHD do not infer emotions more slowly than children without ADHD (d = 0.13), and their small magnitude impairment in accuracy (d = 0.30) was attributable to their generally less accurate performance on choice-response tasks (i.e., across both emotion and control conditions). Taken together, the evidence indicates that emotion inference abilities are likely unimpaired in pediatric ADHD and that working memory is implicated in the ability to infer emotion from context for all children-not just children with ADHD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Towbin K, Vidal-Ribas P, Brotman MA, Pickles A, Miller KV, Kaiser A, Vitale AD, Engel C, Overman GP, Davis M, Lee B, McNeil C, Wheeler W, Yokum CH, Haring CT, Roule A, Wambach CG, Sharif-Askary B, Pine DS, Leibenluft E, Stringaris A. A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. J Am Acad Child Adolesc Psychiatry 2020; 59:350-361. [PMID: 31128268 PMCID: PMC9706653 DOI: 10.1016/j.jaac.2019.05.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 03/08/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Despite the clinical importance of chronic and severe irritability, there is a paucity of controlled trials for its pharmacological treatment. Here, we examine the effects of adding citalopram (CTP) to methylphenidate (MPH) in the treatment of chronic severe irritability in youth using a double-blind randomized placebo-controlled design. METHOD After a lead-in phase of open treatment with stimulant, 53 youth meeting criteria for severe mood dysregulation (SMD) were randomly assigned to receive CTP or placebo (PBO) for 8 weeks. A total of 49 participants, 48 of them (98%) meeting disruptive mood dysregulation disorder (DMDD) criteria, were included in the intent-to-treat analysis. The primary outcome measure was the proportion of response based on improvements of irritability at the week 8 of the trial. RESULTS At the end of the trial, a significantly higher proportion of response was seen in those participants randomly assigned to CTP+MPH compared to PBO+MPH (35% CTP+MPH versus 6% PBO+MPH; odds ratio = 11.70, 95% CI = 2.00-68.16, p = 0.006). However, there were no differences in functional impairment between groups at the end of the trial. No differences were found in any adverse effect between treatment groups, and no trial participant exhibited hypomanic or manic symptoms. CONCLUSION Adjunctive CTP might be efficacious in the treatment of chronic severe irritability in youth resistant to stimulant treatment alone. CLINICAL TRIAL REGISTRATION INFORMATION A Controlled Trial of Serotonin Reuptake Inhibitors Added to Stimulant Medication in Youth With Severe Mood Dysregulation; https://clinicaltrials.gov; NCT00794040.
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Affiliation(s)
- Kenneth Towbin
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.,Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Melissa A. Brotman
- Neuroscience and Novel Therapeutics, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Andrew Pickles
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Katherine V. Miller
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ariela Kaiser
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Aria D. Vitale
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Chana Engel
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | - Mollie Davis
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Beth Lee
- College of Nursing, University of Arizona, Tuscon
| | - Cheri McNeil
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Wanda Wheeler
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Catherine H. Yokum
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Daniel S. Pine
- Section on Development and Affective Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.
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Carlson GA, Klein DN. Editorial: Antidepressants to the Rescue in Severe Mood Dysregulation and Disruptive Mood Dysregulation Disorder? J Am Acad Child Adolesc Psychiatry 2020; 59:339-341. [PMID: 31128267 DOI: 10.1016/j.jaac.2019.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023]
Abstract
Children with irritability and outbursts pose a serous therapeutic problem. Many of them have attention-deficit/hyperactivity disorder (ADHD) with emotion dysregulation, which is sometimes captured in the diagnosis of disruptive mood dysregulation disorder (DMDD). Some follow-up data find a connection between DMDD and depression and anxiety in adults. This prompted Towbin and colleagues1 to launch a trial where children (ages 7-17) with DMDD were treated first with methylphenidate (MPH) and then randomized to citalopram (CTP) or placebo over 8 weeks. The response to CTP was complicated by lack of specific measures of both irritable mood and severity of outbursts. Future studies should include standardized and normed parent and teacher measures of both externalizing and internalizing behavior as well as irritability specific measures rating how the child feels. Studies also need better measures of the actual outbursts-not just their frequency but how agitated or aggressive the child gets during an outburst (ie, what the child does) and how long the outbursts last. Measuring DMDD on inpatient units is especially complicated because of the therapeutic nature of the setting. Further work is needed with much larger samples to identify who improves with the treatment, exactly which domains of psychopathology improve and by how much. Finally, It is also critical to conduct longer-term trials to determine the stability of the response beyond 8 weeks.
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Schepers ST, Arndt DL, Rogers RD, Hedeker D, de Wit H. Subjective responses to amphetamine in young adults with previous mood elevation experiences. Psychopharmacology (Berl) 2019; 236:3363-3370. [PMID: 31209507 PMCID: PMC7053220 DOI: 10.1007/s00213-019-05295-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/02/2019] [Indexed: 12/17/2022]
Abstract
RATIONALE One risk factor for alcohol and substance misuse is hypomanic experiences, or periods of mood elevation. Young people who report hypomanic states are more likely to develop bipolar disorder (BP), and BP and other mood disorders increase the risk of addiction. We recently reported that young adults with a history of mood elevation experience less subjective effects from a low dose of alcohol, which may be predictive of future alcohol use. The finding with alcohol raised the question of whether this dampened response to a drug also applies to other drugs, such as amphetamine. OBJECTIVE This study assessed responses of d-amphetamine in healthy young adults with varying experiences of mood elevation, as measured by the Mood Disorders Questionnaire (MDQ). METHODS Healthy 18-19-year-olds (N = 30) with a range of MDQ scores participated in three 4-h laboratory sessions in which they received placebo, 10 mg, or 20 mg d-amphetamine. They completed mood questionnaires and cardiovascular measures. RESULTS Individuals with higher MDQ scores reported less stimulation and euphoria after 10 mg, but not 20 mg, d-amphetamine, than individuals with lower scores. MDQ scores were not related to cardiovascular responses to the drug. CONCLUSIONS A history of mood elevation experiences or hypomania states is related to dampened response to a low dose of a psychostimulant drug, extending previous findings with dampened response to alcohol. This phenotype for mood disorders of dampened responses to drugs may contribute to risk for subsequent drug use or misuse.
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Affiliation(s)
- Scott T. Schepers
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S Maryland Ave, MC3077, Chicago, IL 60637, USA
| | - David L. Arndt
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S Maryland Ave, MC3077, Chicago, IL 60637, USA
| | | | - Donald Hedeker
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Harriet de Wit
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S Maryland Ave, MC3077, Chicago, IL, 60637, USA.
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Kircanski K, Craske MG, Averbeck BB, Pine DS, Leibenluft E, Brotman MA. Exposure therapy for pediatric irritability: Theory and potential mechanisms. Behav Res Ther 2019; 118:141-149. [PMID: 31085355 PMCID: PMC6590706 DOI: 10.1016/j.brat.2019.04.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/20/2019] [Accepted: 04/17/2019] [Indexed: 01/05/2023]
Abstract
Pediatric irritability is prevalent and impairing, yet little is known about its pathophysiology and treatment. In this article, we build on our and others' previous work to posit core mechanisms of irritability operating across the brain, behavior, and environment. Specifically, we propose proximal processes that surround the symptomatology of irritability and are potential targets for an exposure-based cognitive-behavioral therapy (CBT) for irritability that our group has developed. The heart of this model focuses on neurocognitive processes: youth's encoding of nonreward and threat stimuli, which involves prediction error signaling in the brain, and cognitive control in the context of frustration. Alterations in these processes are theorized to be central to chronic, severe irritability. Environmental responses to youth's symptom expression are also examined. Exposure-based CBT for irritability utilizes controlled, in vivo exposure to nonreward and threat stimuli with the aim to engage cognitive control and target top-down regulation of frustration. This intervention integrates selected parent management training techniques to target symptom reinforcement processes. Continued pathophysiological and treatment studies of irritability will not only refine our emerging understanding of the phenotype, but also inform broader questions on the brain and behavioral mechanisms of CBT efficacy.
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Affiliation(s)
- Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, 9000 Rockville Pike, Building 15K, Bethesda, MD, 20892-2670, USA.
| | - Michelle G Craske
- Department of Psychology, University of California-Los Angeles, 1285 Franz Hall, Los Angeles, CA, 90025, USA
| | - Bruno B Averbeck
- Laboratory of Neuropsychology, National Institute of Mental Health, 9000 Rockville Pike, Building 49, Bethesda, MD, 20892-4415, USA
| | - Daniel S Pine
- Emotion and Development Branch, National Institute of Mental Health, 9000 Rockville Pike, Building 15K, Bethesda, MD, 20892-2670, USA
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, 9000 Rockville Pike, Building 15K, Bethesda, MD, 20892-2670, USA
| | - Melissa A Brotman
- Emotion and Development Branch, National Institute of Mental Health, 9000 Rockville Pike, Building 15K, Bethesda, MD, 20892-2670, USA
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Pan PY, Fu AT, Yeh CB. Aripiprazole/Methylphenidate Combination in Children and Adolescents with Disruptive Mood Dysregulation Disorder and Attention-Deficit/Hyperactivity Disorder: An Open-Label Study. J Child Adolesc Psychopharmacol 2018; 28:682-689. [PMID: 30148656 DOI: 10.1089/cap.2018.0068] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Disruptive mood dysregulation disorder (DMDD) is characterized by nonepisodic irritability and has a high rate of comorbidity with attention-deficit/hyperactivity disorder (ADHD). This is the first study to explore the effects of aripiprazole combined with methylphenidate on clinical symptoms and cognitive functions in patients with DMDD and ADHD. METHODS Patients with DMDD and ADHD (the DMDD-ADHD Group, n = 24; aged 7-17 years) completed a 6-week, open-label trial of aripiprazole and methylphenidate. The pre- and posttreatment outcome measures included the parent-rated Swanson, Nolan, and Pelham Scale-version IV, Child Behavior Checklist, and self-reported Beck Youth Inventories-II, as well as a neuropsychological battery composed of the Children's Color Trail Test and Conner's Continuous Performance Test. The comparison group consisting of patients with ADHD (the ADHD Group, n = 27) was recruited to investigate the differences in clinical and neuropsychological profiles between the two groups at baseline. RESULTS The DMDD-ADHD Group showed worse irritability, disruptive behaviors, anxious/depressed symptoms, and social problems relative to the ADHD Group at baseline assessments. The combination treatment significantly improved irritability, externalizing symptoms, depression, anxiety, attention, social problems, and reaction time variability. The effect sizes of reductions in parent-rated irritability, oppositional defiant symptoms, and inattention were comparable (Cohen's d = 1.26, 1.11, and 1.40, respectively). CONCLUSIONS This pilot study showed the tolerability of the aripiprazole/methylphenidate combination by patients with DMDD and ADHD and its efficaciousness for treating clinical symptoms and for improving cognitive function. Further randomized, controlled, cross-over studies are needed.
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Affiliation(s)
- Pei-Yin Pan
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
| | - An-Ting Fu
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
| | - Chin-Bin Yeh
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
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Ramstad E, Storebø OJ, Gerner T, Krogh HB, Holmskov M, Magnusson FL, Moreira-Maia CR, Skoog M, Groth C, Gillies D, Zwi M, Kirubakaran R, Gluud C, Simonsen E. Hallucinations and other psychotic symptoms in response to methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder: a Cochrane systematic review with meta-analysis and trial sequential analysis . Scand J Child Adolesc Psychiatr Psychol 2018; 6:52-71. [PMID: 33520751 PMCID: PMC7750702 DOI: 10.21307/sjcapp-2018-003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND There is little evidence in the literature on the association between methylphenidate treatment and psychotic symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE We examine the occurrence of psychotic symptoms during methylphenidate treatment of children and adolescents with ADHD. The data arise from our two Cochrane systematic reviews on methylphenidate, reported elsewhere. METHODS Electronic databases were searched up to January 2016 (for observational studies) and March 2017 (for randomized trials). We summarized data as risk ratios and pooled prevalences. Trial Sequential Analysis was used to control for random errors. We assessed the risk of bias and the quality of evidence according to Cochrane guidelines. RESULTS Ten randomized trials (1103 participants), 17 non-randomized studies (76,237 participants) and 12 patient reports or series (18 patients) were identified. In the randomized trials, there was no significant difference in the risk of developing psychotic symptoms [10 of 654 (pooled prevalence, 2.5%) methylphenidate versus 1 of 508 (pooled prevalence, 1.7%) placebo patients; risk ratio, 2.07; 95% confidence interval, 0.58 to 7.35]. Nine of 10 trials had a high risk of bias, and according to the Trial Sequential Analysis, the required information size was not achieved, that is, the meta-analysis was considerably underpowered. There were 873 instances of psychotic symptoms in the non-randomized studies among 55,603 participants (pooled prevalence, 1.2%; 95% confidence interval, 0.7 to 2.4). In the comparative cohort study, methylphenidate significantly increased the risk for any psychotic disorder by 36% (risk ratio, 1.36; 95% confidence interval, 1.17 to 1.57). The overall risk of bias was rated as critical for this study. CONCLUSIONS Because of sparse data and low quality of evidence, we cannot confirm or refute whether methylphenidate increases the risk of psychotic symptoms in children and adolescents with ADHD. This possible adverse event may affect 1.1% to 2.5%, and physicians, patients and caregivers should be aware of this to ensure proper treatment in case of occurrence during methylphenidate treatment.
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Affiliation(s)
- Erica Ramstad
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Trine Gerner
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
| | - Helle B. Krogh
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | | | | | | | - Maria Skoog
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Camilla Groth
- Pediatric Department E, Herlev University Hospital, Herlev, Denmark
| | - Donna Gillies
- Western Sydney Local Health District; Mental Health, Parramatta, Australia
| | | | - Richard Kirubakaran
- Cochrane South Asia, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy, Christian Medical College, Vellore, India
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Stringaris A, Vidal-Ribas P, Brotman MA, Leibenluft E. Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. J Child Psychol Psychiatry 2018; 59:721-739. [PMID: 29083031 DOI: 10.1111/jcpp.12823] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Irritability is one of the most common reasons for referral to child and adolescent mental health services and is the main characteristic of the new diagnosis of disruptive mood dysregulation disorder (DMDD). However, the recognition and management of irritability presents a major challenge in clinical practice and may be partly responsible for the dramatic increase in antipsychotic prescribing in recent years. METHODS In this review, we provide up-to-date information on the definition and mechanisms underlying irritability, and its assessment in clinical practice. We aim to discuss the latest research on DMDD, and the presence of severe irritability in the context of other disorders, as well as to recommend a treatment algorithm. RESULTS Severe irritability is associated with aberrant reward processing and bias toward threatening stimuli. Several measures are available to easily assess irritability. The recent diagnosis of DMDD captures children whose main problem is severe irritability and differ from those with bipolar disorder in longitudinal outcomes, family history, and behavioral and neural correlates. Treatment of irritability might depend on the context it appears. Indirect evidence suggests that parent management training (PMT) and cognitive behavioral therapy (CBT) are the most supported psychological treatments for irritability. CONCLUSIONS Irritability, recognized as a mood problem rather than a purely behavioral manifestation, is a common condition for young people. Practitioners should not ignore irritability as it is associated with substantial morbidity and impairment. Although there are no trials with irritability as main outcome, clinicians can apply several existing pharmacological and psychological interventions for its treatment. Also, new promising approaches relying on pathophysiological findings, such as exposure-based cognitive behavioral therapy techniques and interpretation bias training (IBT), are being currently investigated.
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Affiliation(s)
- Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.,Institute of Psychiatry, Psychology and Neuroscience, Department of Child and Adolescent Psychiatry, King's College London, London, UK
| | - Melissa A Brotman
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
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Carlson GA, Klein DN. Commentary: Frying pan to fire? Commentary on Stringaris et al. (2018). J Child Psychol Psychiatry 2018; 59:740-743. [PMID: 29924397 PMCID: PMC6093282 DOI: 10.1111/jcpp.12873] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 01/28/2023]
Abstract
The bipolar disorder diagnosis in prepubertal children became popular because it answered a clinical need to treat the explosive behavior component of irritability and the hope that antimanic strategies would be helpful. Poor definition of episodes resulted in mixing chronic and episodic irritability in samples of children with bipolar disorder. The subsequent dramatic increase in neuroleptic use is a testimony to the importance of the problem of irritability and our need to better understand it. Insofar as our use of the term irritability conflates proneness to anger with the subsequent aggressive response, it will again not be clear who is being studied. We need to uncouple the mood and behavior aspects of irritability for further study or we will have traded the imprecision of "bipolar" for the imprecision of irritability.
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Affiliation(s)
- Gabrielle A. Carlson
- Professor of Psychiatry and Pediatrics, Stony Brook University School of Medicine
| | - Daniel N. Klein
- Distinguished Professor of Psychology, Stony Brook University
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Winters DE, Fukui S, Leibenluft E, Hulvershorn LA. Improvements in Irritability with Open-Label Methylphenidate Treatment in Youth with Comorbid Attention Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder. J Child Adolesc Psychopharmacol 2018; 28:298-305. [PMID: 29708762 PMCID: PMC6016730 DOI: 10.1089/cap.2017.0124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this open-label study was to examine the effects of long-acting methylphenidate (MPH) treatment on irritability and related emotional symptoms associated with disruptive mood dysregulation disorder (DMDD) in youth with comorbid attention-deficit/hyperactivity disorder (ADHD). METHODS The sample included 22 medication-free male and female subjects (ages 9-15) who met criteria for both DMDD and ADHD. Participants underwent a 4-week trial of long-acting MPH treatment (Concerta®), with weekly dosing increases until a therapeutic dose was reached. Repeated measures t-tests were used to compare pre- and posttreatment ratings of primary and secondary measures. The primary outcome was self-report irritability. Secondary outcomes included parent and child ratings of emotional frequency, emotional lability, and negative affect (NA). Multiple regression was used to examine the impact baseline hyperactivity, age, gender, race, socioeconomic status, or comorbid diagnosis had on treatment outcomes. RESULTS Significant improvements (medium to large effect sizes) in child-rated irritability as well as parent and child ratings of emotional lability, NA, and anger were found. As anticipated, ADHD symptoms also improved. While a majority of the sample saw improvement in child-rated irritability (71%), symptoms worsened a small proportion (19%), and an even smaller portion experienced no change (10%). No demographics, psychiatric comorbidities, or severity of ADHD symptoms influenced treatment outcomes. CONCLUSIONS Study findings suggest that MPH treatment significantly improved mood and emotional symptoms associated with DMDD comorbid with ADHD. These findings, coupled with good tolerability in this open-label pilot study supports further research into the use of MPH as a first-line treatment for DMDD. Future work examining MPH treatment of youth with DMDD with and without comorbid ADHD is needed.
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Affiliation(s)
- Drew E. Winters
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Sadaaki Fukui
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Leslie A. Hulvershorn
- Section of Child and Adolescent Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
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Kircanski K, Clayton ME, Leibenluft E, Brotman MA. Psychosocial Treatment of Irritability in Youth. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2018; 5:129-140. [PMID: 30319935 PMCID: PMC6181450 DOI: 10.1007/s40501-018-0141-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Chronic, severe irritability is a common presenting problem in children and adolescents. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in recognition of this public health need. Currently there are no well-established, evidence-based pharmacological or psychosocial treatments specifically for DMDD. Here, we focus on psychosocial interventions. In addition to reviewing published research, we present preliminary, open trial data on a novel exposure-based cognitive-behavioral therapy (CBT) targeting severe irritability, as is present in DMDD. RECENT FINDINGS In the published literature, parent management training (PMT) comprises parent-based interventions designed to treat youth disruptive behavior. Child-based interventions for disruptive behavior include CBT focused on social cognition and problem-solving. Based on identified treatment gaps for severe irritability in children and adolescents, novel psychosocial interventions are being developed. We have developed a CBT for severe irritability that integrates exposure techniques, drawn from anxiety treatment, with selected PMT techniques. Data from an open pilot trial (N=10) suggest feasibility. SUMMARY Promising psychosocial treatments are being developed for DMDD. Future directions include testing these new therapies against extant interventions. Increased research on the biological and psychological mechanisms mediating irritability will further bridge the treatment gap for youth and families.
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Affiliation(s)
| | | | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health
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Riahi F, Tashakori A, Vanani GS. Effects of Folic Acid on Appetite in Children with Attention Deficit Hyperactivity Disorder (ADHD) Treated with Methylphenidate: A Randomized Double-Blind Clinical Trial. IRANIAN JOURNAL OF MEDICAL SCIENCES 2018; 43:9-17. [PMID: 29398747 PMCID: PMC5776000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The highly effective medications in treating attention deficit hyperactivity disorder (ADHD) symptoms are stimulants like methylphenidate. However, they have adverse effects like reduced appetite. We investigated the effects of folic acid on reduced appetite caused by the use of methylphenidate in children with ADHD. METHODS This randomized double-blind clinical trial evaluated 70 outpatients, aged between 6 and 12 years, with a diagnosis of ADHD. The children were recruited from the Outpatient Child and Adolescent Psychiatric Clinic of Golestan Hospital (Ahwaz, Iran) between 2016 and 2017. The study subjects were randomly assigned to 2 groups: Group 1 received an average dose of methylphenidate (1 mg/kg) plus folic acid (5 mg/d) and Group 2 received an average dose of methylphenidate (1 mg/kg) plus a placebo (5 mg of sucrose) for 8 weeks. Assessments, comprising the Conners Parent Questionnaire, anthropometric measurements, and appetite questionnaire, were conducted by a psychiatrist at baseline and then at 2, 4, 6, and 8 weeks after the medication was started using repeated measure analysis. The data were analyzed with the Mann-Whitney U and ANOVA tests using the SPSS statistical software (v. 18.0). RESULTS Age and gender were not associated with the groups. Weight, height, and the body mass index were not changed during the study in both groups. ADHD symptoms significantly decreased in both groups during the trial; however, no difference was observed between the groups. Moreover, appetite was significantly improved in Group 1. Both medications were well tolerated. CONCLUSION It seems that folic acid improved the reduced appetite caused by the use of methylphenidate in our children with ADHD. Trial Registration Number: IRCT2016040927304N1.
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Affiliation(s)
- Forough Riahi
- Department of Psychiatry, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ashraf Tashakori
- Department of Psychiatry, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ghazal Salehi Vanani
- Department of Psychiatry, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran,Correspondence: Ghazal Salehi Vanani, MD;Department of Psychiatry, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Tel: +98 939 0352301 Fax: +98 61 33743038
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TDAH et comorbidités en pédopsychiatrie. Pathologies psychiatriques, affections médicales, troubles de l’apprentissage et de la coordination. ANNALES MEDICO-PSYCHOLOGIQUES 2017. [DOI: 10.1016/j.amp.2015.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Affiliation(s)
- Melissa A. Brotman
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
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Waxmonsky JG, Mayes SD, Calhoun SL, Fernandez-Mendoza J, Waschbusch DA, Bendixsen BH, Bixler EO. The association between Disruptive Mood Dysregulation Disorder symptoms and sleep problems in children with and without ADHD. Sleep Med 2017; 37:180-186. [PMID: 28899532 DOI: 10.1016/j.sleep.2017.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/13/2017] [Accepted: 02/15/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many youth experience persistent irritability and recurrent temper outbursts, conceptualized by DSM-5 as Disruptive Mood Dysregulation Disorder (DMDD). Sleep deprivation impairs emotion regulation which could increase rates of DMDD symptoms, especially in those with preexisting regulatory impairments, as seen with ADHD. However, there has been little examination of the relationship between chronic sleep problems and DMDD symptoms. METHODS Associations between DMDD symptoms and sleep parameters in children were assessed using parent-report and objective measures of sleep in a general population sample (N = 665) and an ADHD sample (N = 784). Irritability, temper outbursts, sleep problems and other psychological problems were assessed with the Pediatric Behavior Scale. The general population study also completed overnight polysomnography (PSG). RESULTS DMDD symptoms were reported in 9.2% of the community sample and 31.4% of the ADHD sample. In both samples, children with DMDD symptoms had significantly higher parent-reported sleep problems than children without DMDD symptoms. Children with sleep problems had significantly higher DMDD scores than children without sleep problems. However, DMDD symptoms were most strongly associated with oppositional behavior. Sleep problems were not a significant contributor. Hyperactivity-impulsivity was most strongly associated with sleep problems, and DMDD was not a significant contributor. Children with and without DMDD symptoms did not differ significantly on any PSG parameter. CONCLUSIONS Associations between parent-reported sleep problems and DMDD symptoms were due to their shared relationship with other behavioral problems. Therefore, chronic sleep problems do not appear to be a primary source of DMDD symptoms in children with or without ADHD.
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Affiliation(s)
- James G Waxmonsky
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA.
| | - Susan D Mayes
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - Susan L Calhoun
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | | | | | | | - Edward O Bixler
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
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Birkle SM, Legenbauer T, Grasmann D, Holtmann M. Disruptive Affektregulations- störung: eine umstrittene neue Diagnose im DSM-5. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:98-103. [DOI: 10.1024/1422-4917/a000496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Die Disruptive Affektregulationsstörung wurde in die 5. Auflage des DSM erstmals als Störungsbild aufgenommen. Den Anlass, eine eigenständige diagnostische Kategorie im Kapitel „Depressive Störungen“ für einen Verhaltensphänotyp aus chronischer, nichtepisodischer Reizbarkeit und häufigen plötzlichen Wutanfällen zu entwickeln, gab die transatlantische Kontroverse um das klinische Bild und die Prävalenz früh beginnender bipolarer Störungen. Die vorliegende Arbeit stellt erste vorliegende Arbeiten dar, die auf die neuen Kriterien zurückgreifen. Während die Abgrenzbarkeit der Disruptiven Affektregulationsstörung in Symptomatik und Verlauf von bipolaren Störungen gut gelingt, finden sich Hinweise auf starke Überlappungen mit oppositionell-gereizten Symptombildern. Für die anstehende Revision der ICD sollte daher diskutiert werden, keine neue Diagnose, sondern eher eine Zusatzcodierung einzuführen, die kennzeichnet, ob eine oppositionelle Störung auch reizbar-wütendes Verhalten umfasst. Unabhängig von der nosologischen Einordnung besteht die Herausforderung, den Verhaltensphänotyp hinsichtlich Ätiologie, Entwicklungspsychopathologie und Prognose besser zu verstehen und hilfreiche Behandlungsmöglichkeiten zu entwickeln.
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Affiliation(s)
- Sarah Maria Birkle
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
| | - Tanja Legenbauer
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
| | - Dörte Grasmann
- Verhaltenstherapie-Ambulanz für Kinder und Jugendliche, Klinische Psychologie und Psychotherapie, Goethe-Universität, Frankfurt am Main
| | - Martin Holtmann
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
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Irritability in child and adolescent psychopathology: An integrative review for ICD-11. Clin Psychol Rev 2017; 53:29-45. [PMID: 28192774 DOI: 10.1016/j.cpr.2017.01.004] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 01/02/2017] [Accepted: 01/16/2017] [Indexed: 12/13/2022]
Abstract
In preparation for the World Health Organization's development of the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11) chapter on Mental and Behavioral Disorders, this article reviews the literature pertaining to severe irritability in child and adolescent psychopathology. First, research on severe mood dysregulation suggests that youth with irritability and temper outbursts, among other features of hyperactivity and arousal, demonstrate cross-sectional correlates and developmental outcomes that distinguish them from youth with bipolar disorder. Second, other evidence points to an irritable dimension of Oppositional Defiant Disorder symptomatology, which is uniquely associated with concurrent and subsequent internalizing problems. In contrast to the Diagnostic and Statistical Manual of Mental Disorders' (5th ed.) Disruptive Mood Dysregulation Disorder, our review of the literature supports a different solution: a subtype, Oppositional Defiant Disorder with chronic irritability/anger (proposal included in Appendix). This solution is more consistent with the available evidence and is a better fit with global public health considerations such as harm/benefit potential, clinical utility, and cross-cultural applicability. Implications for assessment, treatment, and research are discussed.
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Benarous X, Consoli A, Guilé JM, Garny de La Rivière S, Cohen D, Olliac B. Evidence-based treatments for youths with severely dysregulated mood: a qualitative systematic review of trials for SMD and DMDD. Eur Child Adolesc Psychiatry 2017; 26:5-23. [PMID: 27662894 DOI: 10.1007/s00787-016-0907-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/16/2016] [Indexed: 01/14/2023]
Abstract
The aim of this literature review was to examine the evidence for psychotherapeutic and pharmacological treatments in subjects with severely dysregulated mood and to identify potential areas for improvements in research designs. A literature search was conducted using several databases for published (PubMed, PsycINFO) and ongoing (clinical trial registries) studies conducted in youths who met NIMH's criteria for Severe Mood Dysregulation (SMD) or the DSM-5 diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). Eight completed studies were identified: three randomized trials, four open pilot studies and one case report. Seven ongoing studies were found in trial registries. The available evidence suggests potential efficacy of psychotherapies which have previously been developed for internalizing and externalizing disorders. The two main pharmacological strategies tested are, first, a monotherapy of psychostimulant or atypical antipsychotic such as risperidone, already used in the treatment of severe irritability in youths with developmental disorders; and second, the use of a serotonergic antidepressant as an add-on therapy in youths treated with psychostimulant. Ongoing studies will further clarify the effectiveness of psychotherapeutic interventions for DMDD individuals and whether they should be given alone or in conjunction with other treatments. The short duration of the trials for a chronic disorder, the low number of studies, the lack of placebo or active comparator arm, and restrictive inclusion criteria in most of the controlled trials dramatically limit the interpretation of the results. Finally, future research should be conducted across multiple sites, with standardized procedures to measure DMDD symptoms reduction, and include a run-in period to limit placebo effect.
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Affiliation(s)
- Xavier Benarous
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.
| | - Angèle Consoli
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,INSERM U-669, PSIGIAM, Paris, France
| | - Jean-Marc Guilé
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,Groupe de Recherches sur l'Analyse Multimodale de la Fonction Cérébrale, INSERM U1105, CHU, Université Picardie Jules Verne, Amiens, France.,Department of Psychiatry, McGill University, Montreal, Canada
| | - Sébastien Garny de La Rivière
- Groupe de Recherches sur l'Analyse Multimodale de la Fonction Cérébrale, INSERM U1105, CHU, Université Picardie Jules Verne, Amiens, France
| | - David Cohen
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,CNRS UMR 7222, Institute for Intelligent Systems and Robotics-ISIR, Paris, France
| | - Bertrand Olliac
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,Pôle Hospitalo-Universitaire de psychiatrie de l'enfant et de l'adolescent, Centre Hospitalier Esquirol, Limoges, France
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Abstract
Individuals with attention-deficit/hyperactivity disorder (ADHD) experience impairments in a number of functional domains. Although current evidence-based treatments for ADHD reduce symptoms and improve academic and behavioral functioning, they have minimal impact on social functioning or on risky behaviors (see Evans et al. in J Clin Child Adolesc Psychol, 43:527-551, 2014 for review). Preliminary evidence indicates that emotion dysregulation (ED) is associated with impairments across the developmental spectrum, such as social impairment and risky behaviors, and that its relative absence/presence is differentially associated with treatment response. It thus stands to reason that by incorporating a focus on ED in interventions targeting social impairment and risky behaviors, we may be able to increase the number of youth who respond to such interventions and decrease the prevalence or degree of these impairments and behaviors among youth and adults with ADHD. However, a number of questions remain unaddressed about the association between ADHD and ED, such as the portion of individuals with ADHD who experience ED, the extent to which ED is associated with the above impairments and behaviors, and whether or not ED is malleable. To begin addressing these questions, we summarize and critically evaluate the literature on the association between ADHD and ED and make recommendations for future basic, translational, and treatment outcome research.
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Mayes SD, Mathiowetz C, Kokotovich C, Waxmonsky J, Baweja R, Calhoun SL, Bixler EO. Stability of Disruptive Mood Dysregulation Disorder Symptoms (Irritable-Angry Mood and Temper Outbursts) Throughout Childhood and Adolescence in a General Population Sample. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2016; 43:1543-1549. [PMID: 26004122 DOI: 10.1007/s10802-015-0033-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
DSM-5 Disruptive Mood Dysregulation Disorder (DMDD) is a controversial new diagnosis. The DSM-5 conceptualizes DMDD as persistent and chronic, but the stability of the two DMDD symptoms (irritable-angry mood and temper outbursts) over time is not known. Mothers rated DMDD symptoms in a population-based sample of 376 children (54 % male) evaluated at 6-12 years (M 9) and again an average of 8 years later (M 16). Mean scores on irritable-angry mood plus temper outbursts at baseline and follow-up were below sometimes a problem, but were higher at baseline than follow-up. Irritable-angry mood and temper outbursts were both often or very often a problem for 9 % of children at baseline, 6 % at follow-up, and 3 % at baseline and follow-up. Only 29 % of children whose baseline symptoms were often or very often continued to have follow-up symptoms at this level (remission rate 71 %). Less than half (45 %) of the children whose symptoms were often or very often at follow-up had these symptoms 8 years earlier (55 % new cases). Our finding of 71 % remission and 55 % new cases indicates instability of DMDD symptoms over an 8-year period. However, the finding that 29 % still had symptoms often or very often 8 years later is clinically significant. DMDD symptoms were found in only one child who did not have symptoms of oppositional defiant disorder (ODD), conduct disorder, ADHD, anxiety, or depression. This suggests that DMDD symptoms are a feature of multiple disorders, particularly ODD, and do not occur in isolation, questioning the validity of DMDD as a unique and independent diagnosis.
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Affiliation(s)
- S D Mayes
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA.
| | - C Mathiowetz
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - C Kokotovich
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - J Waxmonsky
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - R Baweja
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - S L Calhoun
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
| | - E O Bixler
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, USA
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Vidal-Ribas P, Brotman MA, Valdivieso I, Leibenluft E, Stringaris A. The Status of Irritability in Psychiatry: A Conceptual and Quantitative Review. J Am Acad Child Adolesc Psychiatry 2016; 55:556-70. [PMID: 27343883 PMCID: PMC4927461 DOI: 10.1016/j.jaac.2016.04.014] [Citation(s) in RCA: 298] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/27/2016] [Accepted: 04/29/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Research and clinical interest in irritability have been on the rise in recent years. Yet several questions remain about the status of irritability in psychiatry, including whether irritability can be differentiated from other symptoms, whether it forms a distinct disorder, and whether it is a meaningful predictor of clinical outcomes. In this article, we try to answer these questions by reviewing the evidence on how reliably irritability can be measured and its validity. METHOD We combine a narrative and systematic review and meta-analysis of studies. For the systematic review and meta-analysis, we searched studies in PubMed and Web of Science based on preselected criteria. A total of 163 articles were reviewed, and 24 were included. RESULTS We found that irritability forms a distinct dimension with substantial stability across time, and that it is specifically associated with depression and anxiety in longitudinal studies. Evidence from genetic studies reveals that irritability is moderately heritable, and its overlap with depression is explained mainly by genetic factors. Behavioral and neuroimaging studies show that youth with persistent irritability exhibit altered activations in the amygdala, striatum, and frontal regions compared with age-matched healthy volunteers. Most knowledge about the treatment of irritability is based on effects of treatment on related conditions or post hoc analyses of trial data. CONCLUSION We identify a number of research priorities including innovative experimental designs and priorities for treatment studies, and conclude with recommendations for the assessment of irritability for researchers and clinicians.
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Affiliation(s)
- Pablo Vidal-Ribas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
| | - Melissa A Brotman
- Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Isabel Valdivieso
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Ellen Leibenluft
- Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Argyris Stringaris
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
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Banaschewski T, Gerlach M, Becker K, Holtmann M, Döpfner M, Romanos M. Trust, but verify. The errors and misinterpretations in the Cochrane analysis by O. J. Storebo and colleagues on the efficacy and safety of methylphenidate for the treatment of children and adolescents with ADHD. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2016; 44:307-14. [PMID: 27270192 DOI: 10.1024/1422-4917/a000433] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objective A recent Cochrane review published by O. J. Storebo and colleagues (2015) raised substantial doubts about the benefit from stimulant medication with methylphenidate in the treatment of childhood ADHD due to the overall poor quality of studies. The systematic review thus contradicts all previous reviews and meta-analyses. Method We here detail various examples of errors, inconsistencies, and misinterpretations in the review which led to false results and inadequate conclusions. Results We demonstrate that the study selection is flawed and undertaken without sufficient scientific justification resulting in an underestimation of effect sizes, which, furthermore, are inadmissibly clinically interpreted. The methodology of the assessment of bias and quality is not objective and cannot be substantiated by the data. Conclusions Cochrane reviews lay claim to a high scientific quality and substantial relevance for evidence-based clinical decisions. The systematic review by Storebo and colleagues (2015) illustrates that, despite adhering to strict standards and high-quality protocols, even Cochrane works should be critically read and verified, sometimes with surprising results.
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Affiliation(s)
- T Banaschewski
- 1 Zentralinstitut für Seelische Gesundheit Mannheim, Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters (KJP)
| | - M Gerlach
- 2 Zentrum für Psychische Gesundheit, Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg
| | - K Becker
- 3 Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Gießen und Marburg
| | - M Holtmann
- 4 Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik, LWL-Universtitätsklinik Hamm der Ruhr-Universität Bochum
| | - M Döpfner
- 5 Ausbildungsinstitut für Kinder- und Jugendlichenpsychotherapie (AKiP) am Klinikum der Universität zu Köln.,6 Medizinische Fakultät, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universität zu Köln
| | - M Romanos
- 2 Zentrum für Psychische Gesundheit, Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg
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Correction to "The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder across Home and School". J Child Adolesc Psychopharmacol 2016:cap.2015.0053.cxn. [PMID: 26938370 DOI: 10.1089/cap.2015.0053.cxn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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50
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Mayes SD, Waxmonsky JD, Calhoun SL, Bixler EO. Disruptive Mood Dysregulation Disorder Symptoms and Association with Oppositional Defiant and Other Disorders in a General Population Child Sample. J Child Adolesc Psychopharmacol 2016; 26:101-6. [PMID: 26745442 PMCID: PMC4800381 DOI: 10.1089/cap.2015.0074] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnosis, disruptive mood dysregulation disorder (DMDD), has generated appreciable controversy since its inception, primarily in regard to its validity as a distinct disorder from oppositional defiant disorder (ODD). The goal of our study was to determine if the two DSM-5 DMDD symptoms (persistently irritable or angry mood and severe recurrent temper outbursts) occurred independently of other disorders, particularly ODD. Other DSM-5 DMDD criteria were not assessed. METHODS Maternal ratings of the two DMDD symptoms, clinical diagnosis of ODD using DSM-5 symptom criteria, and psychological problem scores (anxiety, depression, oppositional behavior, conduct disorder, and attention-deficit/hyperactivity disorder [ADHD]) on the Pediatric Behavior Scale were analyzed in a population sample, 6-12 years of age (n = 665). RESULTS The prevalence of DMDD symptoms (irritable-angry mood and temper outbursts both rated by mothers as often or very often a problem) was 9%. In all, 92% of children with DMDD symptoms had ODD, and 66% of children with ODD had DMDD symptoms, indicating that it is very unlikely to have DMDD symptoms without ODD, but that ODD can occur without DMDD symptoms. Comorbid psychological problems (anxiety, depression, conduct disorder, and ADHD) in addition to ODD did not increase the risk of having DMDD symptoms beyond that for ODD alone. Only 3% of children with psychological problems other than ODD had DMDD symptoms. CONCLUSIONS Our general population findings are similar to those for a psychiatric sample, suggesting that DMDD cannot be differentiated from ODD based on symptomatology. Therefore, it is important to assess all DSM criteria and to examine for comorbid psychopathology when considering a diagnosis of DMDD. Our results support the recommendation made by the World Health Organization's International Classification of Diseases, 11th Revision (ICD-11) panel of experts that DMDD symptoms may be more appropriately classified as an ODD specifier than a separate diagnosis.
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Affiliation(s)
- Susan D. Mayes
- Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania
| | - James D. Waxmonsky
- Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania
| | - Susan L. Calhoun
- Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania
| | - Edward O. Bixler
- Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania
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