Dataset Information

Psychosocial Treatment of Irritability in Youth.

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.

SUBMITTER: Kircanski K

PROVIDER: S-EPMC6181450 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Publications

Psychosocial Treatment of Irritability in Youth.

Kircanski Katharina K Clayton Michal E ME Leibenluft Ellen E Brotman Melissa A MA

Current treatment options in psychiatry 20180209 1

<h4>Purpose of review</h4>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- ...[more]

PMID: 30319935

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Project description:BackgroundIrritability is a common and impairing occurrence in autistic youth, yet the underlying mechanisms are not well-known. In typically developing populations, differences in frustration response have been suggested as important driver of the behavioural symptoms of irritability. Research exploring the role of frustration response as a risk factor for irritability in autistic populations is limited and often uses parent report or observer ratings; objective measures of frustration response appropriate for use in autistic populations are required to advance the field.MethodsIn the current study, fifty-two autistic adolescents aged 13-17 years from a population-based longitudinal study completed an experimental task designed to induce frustration through exposure to periods of unexpected delay. Behavioural (number of button presses) and physiological (heart rate; HR) metrics were collected during delay periods. Irritability was measured using the parent-rated Affective Reactivity Index (ARI). Analyses used mixed-level models to test whether irritability was associated with different slopes of behavioural and physiological response to experimentally induced frustration during the task. Age and baseline HR (for the physiological data only) were included as covariates.ResultsAnalyses showed a marginal association between irritability and the slope of behavioural response (incident rate ratio (IRR) =.98, p=.06), and a significant association with the slope of physiological response (b=-.10, p=.04); higher levels of irritability were associated with a dampened behavioural and physiological response, as indicated by flatter slopes of change over the course of the task. The pattern of results largely remained in sensitivity analyses, although the association with physiological response became non-significant when adjusting for IQ, autism symptom severity, and medication use (b=-.10, p=.10).ConclusionsResults suggest that the current experimental task may be a useful objective measure of frustration response for use with autistic populations, and that a non-adaptive response to frustration may be one biological mechanism underpinning irritability in autistic youth. This may represent an important target for future intervention studies.

Project description:Importance:Comorbidity is ubiquitous in psychiatry, but it is unclear how to differentiate neural mechanisms of co-occurring symptoms. Pediatric irritability and anxiety symptoms are prevalent and frequently co-occur. Threat orienting is pertinent to both phenotypes and is an ideal context in which to examine their unique and common neural mechanisms. Objectives:To decompose the unique and shared variances of pediatric irritability and anxiety symptoms and to determine neural correlates of these differentiated phenotypes during threat orienting. Design, Setting, and Participants:This investigation was a cross-sectional functional magnetic resonance imaging study. The setting was a research clinic at the National Institute of Mental Health. Participants were youth aged 8 to 18 years spanning multiple diagnostic categories (141 youth with disruptive mood dysregulation disorder, anxiety disorder, and/or attention-deficit/hyperactivity disorder and 56 healthy youth). This combination provided wide variation in levels of irritability and anxiety symptoms. Data were acquired between June 30, 2012, and June 28, 2016. Main Outcomes and Measures:Participants and parents rated youth's irritability on the Affective Reactivity Index and anxiety on the Screen for Child Anxiety Related Emotional Disorders. Bifactor analysis decomposed the unique and shared variances. A functional magnetic resonance imaging dot-probe task assessed attention orienting to angry (ie, threat) vs neutral faces. Whole-brain analyses examined associations between the bifactor-derived phenotypes and both neural activity and amygdala functional connectivity. Results:Among 197 participants included in the final analysis, the mean (SD) age was 13.1 (2.7) years, and 91 (46.2%) were female. The best-fit bifactor model (Comparative Fit Index, 0.959; Root Mean Square Error of Approximation, 0.066) included unique factors of parent-reported irritability, youth-reported irritability, and anxiety, as well as a common factor of negative affectivity. When the task required attention away from threat, higher parent-reported irritability was associated with increased activity in the insula, caudate, dorsolateral and ventrolateral prefrontal cortex, and inferior parietal lobule (t189?4.15 for all, P?<?.001 for all). In contrast, higher anxiety was associated with decreased amygdala connectivity to the cingulate, thalamus, and precentral gyrus (t189?-4.19 for all, P?<?.001 for all). These distinctive neural correlates did not emerge using a diagnostic approach. Conclusions and Relevance:A latent variable approach to parsing co-occurring symptom dimensions revealed a novel double dissociation. During orientation away from threat, only irritability was associated with neural activity, whereas only anxiety was associated with amygdala connectivity. Despite the challenges of symptom co-occurrence for clinical neuroscience, data-driven phenotyping may facilitate a path forward.

Project description:Background: Severe irritability is a common, impairing problem among youth referred for mental health services, but evidence to guide care is limited. Treatment research can be advanced by adopting a transdiagnostic perspective, leveraging existing evidence-based treatment (EBT) techniques, and situating irritability within the context of emotion dysregulation. Accordingly, this study examined treatment outcomes for youth with different levels of irritability and dysregulation who received cognitive-behavioral therapy (CBT) or behavioral parent training (BPT) in a modular EBT framework. Method: We analyzed data from a community-based implementation trial of a transdiagnostic youth psychotherapy. Two-hundred treatment-referred youths (7-15 years; 47% female; 33% White, 28% Black, 24% Latinx, 14% multiracial, 2% other) and their caregivers completed measures of clinical problems and emotion dysregulation at baseline, with repeated outcomes assessments over 18 months. First, latent profile analysis was applied to baseline irritability and emotion dysregulation data; then, latent growth curve models were used to examine outcome trajectories, controlling for covariates. Results: A two-class solution fit well, differentiating youth with high (n = 54) vs. low (n = 146) levels of dysregulation and irritability at baseline. Nearly all high-dysregulation youth received either BPT (n = 26) or CBT-Depression (n = 23). Across measures, both groups showed statistically and clinically significant improvements over time. High-dysregulation youth had greater baseline severity than low-dysregulation youth, but otherwise their longitudinal trajectories were mostly similar, with few between-group slope differences. There was virtually no evidence of differential effects for BPT vs. CBT on clinical outcomes. Conclusions: Youth with severe irritability and dysregulation, treated with a transdiagnostic, modular, EBT approach, showed significant within-person improvements over time. Their outcome trajectories did not differ according to whether they received BPT or CBT. Findings extend the literature on modular, transdiagnostic, and EBT approaches for irritability and dysregulation, suggesting comparable benefits associated with BPT and CBT when treatment selection is guided by comprehensive assessment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03153904.

Dataset Information

Psychosocial Treatment of Irritability in Youth.

Purpose of review

Recent findings

Summary

Publications

Psychosocial Treatment of Irritability in Youth.

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