Across-subjects multiple baseline trial of exposure-based cognitive-behavioral therapy for severe irritability: a study protocol

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Irritability in Youths: A Critical Integrative Review

Irritability, defined as proneness to anger that may impair an individual's functioning, is common in youths. There has been a recent upsurge in relevant research. The authors combine systematic and narrative review approaches to integrate the latest clinical and translational findings and provide suggestions for addressing research gaps. Clinicians and researchers should assess irritability routinely, and specific assessment tools are now available. Informant effects are prominent, are stable, and vary by age and gender. The prevalence of irritability is particularly high among individuals with attention deficit hyperactivity disorder, autism spectrum disorder, and mood and anxiety disorders. Irritability is associated with impairment and suicidality risk independent of co-occurring diagnoses. Developmental trajectories of irritability (which may begin early in life) have been identified and are differentially associated with clinical outcomes. Youth irritability is associated with increased risk of anxiety, depression, behavioral problems, and suicidality later in life. Irritability is moderately heritable, and genetic associations differ based on age and comorbid illnesses. Parent management training is effective for treating psychological problems related to irritability, but its efficacy in treating irritability should be tested rigorously, as should novel mechanism-informed interventions (e.g., those targeting exposure to frustration). Associations between irritability and suicidality and the impact of cultural context are important, underresearched topics. Analyses of large, diverse longitudinal samples that extend into adulthood are needed. Data from both animal and human research indicate that aberrant responses to frustration and threat are central to the pathophysiology of irritability, revealing important translational opportunities.

An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

OBJECTIVE

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

METHOD

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

RESULTS

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

CONCLUSIONS

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

Can peripheral psychophysiological markers predict response to exposure-based cognitive behavioral therapy in youth with severely impairing irritability? A study protocol

BACKGROUND

Irritability, an increased proneness to anger, is a primary reason youth present for psychiatric care. While initial evidence supports the efficacy of exposure-based cognitive behavioral therapy (CBT) for youth with clinically impairing irritability, treatment mechanisms remain unclear. Here, we propose to measure peripheral psychophysiological indicators of arousal-heart rate (HR)/electrodermal activity (EDA)-and regulation-heart rate variability (HRV)-during exposures to anger-inducing stimuli as potential predictors of treatment efficacy. The objective of this study is to evaluate whether in-situ biosensing data provides peripheral physiological indicators of in-session response to exposures.

METHODS

Blood volume pulse (BVP; from which HR and HRV canl be derived) and EDA will be collected ambulatorily using the Empatica EmbracePlus from 40 youth (all genders; ages 8-17) undergoing six in-person exposure treatment sessions, as part of a multiple-baseline trial of exposure-based CBT for clinically impairing irritability. Clinical ratings of irritability will be conducted at baseline, weekly throughout treatment, and at 3-month and 6-month follow-ups via the Clinical Global Impressions Scale (CGI) and the Affective Reactivity Index (ARI; clinician-, parent-, and child-report). Multilevel modeling will be used to assess within- and between-person changes in physiological arousal and regulation throughout exposure-based CBT and to determine whether individual differences are predictive of treatment response.

DISCUSSION

This study protocol leverages a wearable biosensor (Empatica) to continuously record HR/HRV (derived from BVP) and EDA during in-person exposure sessions for youth with clinically impairing irritability. Here, the goal is to identify changes in physiological arousal (EDA, HR) and regulation (HRV) over the course of treatment in tandem with changes in clinical symptoms.

TRIAL REGISTRATION

The participants in this study come from an overarching clinical trial (trial registration numbers: NCT02531893 first registered on 8/25/2015; last updated on 8/25/2023). The research project and all related materials were submitted and approved by the appropriate Institutional Review Board of the National Institute of Mental Health (NIMH).

Future Directions in Youth Irritability Research

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

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

A Cognitive Behavioral Computing Model Combined with DM’s Teaching Quality Improvement

There are more and more ideas of applying data research science to replace theoretical research science, including monitoring and evaluation of school teaching quality. In order to distinguish different types of learners through knowledge and behavior performance, so as to better improve the teaching quality of teachers, a data mining model based on knowledge expression and calculation mode is provided. According to all the key cognitive and behavioral input parameters and cognitive and behavioral index factors, through the collection of artificial neural networks, sensitivity analysis, data mining, and classification regression trees, they are divided into three types of differences, so as to better adopt differentiation strategies for learners with different types. The experimental results also show that the behavior parameters are far more critical than the knowledge parameters. The research results show that the model is effective in supporting teachers' work in the education system.

Irritability and mental health profiles among children and adolescents: A result of latent profile analysis

BACKGROUND

Irritability is a transdiagnostic symptom that accompanies both internalizing and externalizing problems. However, there has been a scarcity of research concerning the relationships between irritability and mental health profiles among children and adolescents.

AIM

This study aimed to identify latent profiles in children and adolescents using anxiety, depression, oppositionality, and irritability. In addition, the profiles were further examined in their relationships with mental health symptoms.

METHOD

The study analyzed data from 1867 children and adolescents aged 6-15 years from the COVID-19 Online-Survey for Children and Adolescents in Japan (J-COSCA). Parent-reported questionnaires were used in this study.

RESULTS

A latent profile analysis detected five latent profiles. High oppositionality characterized the first profile ("oppositional": n = 405, 22%). High levels of depression and other less pronounced symptoms characterized the second profile ("depressed": n = 276, 15%). The third profile ("average": n = 602, 33%) presented average symptoms of anxiety, depression and oppositionality and low irritability. The fourth profile ("well-adjusted": n = 235, 13%) presented low values for all the applicable symptoms. The last profile ("comorbid": n = 308, 17%) exhibited high values for all the symptoms and the highest level of irritability of the five profiles.

LIMITATION

We analyzed the data from a community sample alone after capturing it using parent-reported questionnaires.

CONCLUSION

This study revealed that the five profiles (oppositional, depressed, average, well-adjusted, and comorbid) were identified, and children and adolescents in the comorbid profiles had high irritability as well as high anxiety, depression, and oppositionality.

Associations of Sociodemographic Factors and Health Behaviors with the Emotional Well-Being of Adolescents during the COVID-19 Pandemic in Brazil

This cross-sectional study utilizes data from a nationwide web-based survey aimed to identify the factors affecting the emotional well-being of Brazilian adolescents aged 12–17 during the period of school closures and confinement. Data collection took place from 27 June to 17 September 2020. We used the “virtual snowball” sampling method, and students from private and public schools were included. A total of 9470 adolescents were analyzed. A hierarchical logistic regression model was used to find the factors associated with reporting at least two of three self-reported problems—sadness, irritability, and sleep problems. The main proximal factor was loneliness (AdjOR = 8.12 p < 0.001). Problems related to school closures also played an important role. Regular intake of fruits and vegetables, as well as physical activity, demonstrated a positive influence on emotional well-being, while excessive screen time (AdjOR = 2.05, p < 0.001) and alcohol consumption negatively affected outcomes (AdjOR = 1.73, p < 0.001). As for distal variables, less affluent adolescents were the most affected, and males reported fewer emotional problems than females. Uncertainty regarding the disease in a context of socioeconomic vulnerability, together with rises in unhealthy behaviors and isolation from their immediate social circles, have negatively affected adolescents’ emotional status throughout the COVID-19 pandemic.