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.

Emotion regulation as central to psychopathology across childhood and adolescence: a commentary on Nobakht et al. (2023)

An important goal of clinical/developmental research is to identify factors contributing to the onset and maintenance of psychopathology - particularly factors that could be modified through intervention. Large-scale, multi-informant, longitudinal studies provide valuable opportunities for testing such etiological hypotheses, as illustrated by Nobakht et al.'s recent six-wave cohort study spanning ages 4-14. At a within-person level, emotion regulation (ER) deficits consistently predicted oppositional defiant disorder (ODD) symptoms (including both irritability and defiance), whereas victimization did not. These results comport with growing evidence highlighting ER's centrality to ODD and psychopathology more broadly. While the ER findings carry promising implications, caution is warranted in interpreting the results for victimization given that its association with psychopathology is well-documented. More research is needed to test precise questions about within- and between-person processes involving ER, victimization, and psychopathology across development. Pressing research questions include whether, how, and when youths' ER can be modified, and with what effects on clinical outcomes.

Evidence Base Update on the Assessment of Irritability, Anger, and Aggression in Youth

OBJECTIVE

Irritability, anger, and aggression have garnered significant attention from youth mental health researchers and clinicians; however, fundamental challenges of conceptualization and measurement persist. This article reviews the evidence base for assessing these transdiagnostic constructs in children and adolescents.

METHOD

We conducted a preregistered systematic review of the evidence behind instruments used to measure irritability, anger, aggression, and related problems in youth. Searches were conducted in PsycINFO and PubMed, identifying 4,664 unique articles. Eligibility criteria focused on self- and proxy-report measures with peer-reviewed psychometric evidence from studies in English with youths ages 3-18. Additional measures were found through ancillary search strategies (e.g. book chapters, review articles, test publishers). Measures were screened and coded by multiple raters with acceptable reliability.

RESULTS

Overall, 68 instruments met criteria for inclusion, with scales covering irritability (n = 15), anger (n = 19), aggression (n = 45), and/or general overt externalizing problems (n = 27). Regarding overall psychometric support, 6 measures (8.8%) were classified as Excellent, 46 (67.6%) were Good, and 16 (23.5%) were Adequate. Descriptive information (e.g. informants, scales, availability, translations) and psychometric properties (e.g. reliability, validity, norms) are summarized.

CONCLUSIONS

Numerous instruments for youth irritability, anger, and aggression exist with varying degrees of empirical support for specific applications. Although some measures were especially strong, none had uniformly excellent properties across all dimensions, signaling the need for further research in particular areas. Findings promote conceptual clarity while also producing a well-characterized toolkit for researchers and clinicians addressing transdiagnostic problems affecting youth.

The Affective Side of Disruptive Behavior: Toward Better Understanding, Assessment, and Treatment

Historically, much of the progress made in youth mental health research can be classified as focusing on externalizing problems, characterized by disruptive behavior (e.g. aggression, defiance), or internalizing problems, characterized by intense negative affect (e.g. depression, anxiety). Until recently, however, less attention has been given to topics that lie somewhere in between these domains, topics that we collectively refer to as the affective side of disruptive behavior. Like the far side of the moon, the affective side of disruptive behavior captures facets of the phenomenon that may be less obvious or commonly overlooked, but are nonetheless critical to understand. This affective side clarifies socially disruptive aspects of traditionally "externalizing" behavior by elucidating proximal causation via intense negative affect (traditionally "internalizing"). Such problems include irritability, frustration, anger, temper loss, emotional outbursts, and reactive aggression. Given a recent explosion of research in these areas, efforts toward integration are now needed. This special issue was developed to help address this need. Beyond the present introductory article, this collection includes 4 empirical articles on developmental psychopathology topics, 4 empirical articles on applied treatment/assessment topics, 1 evidence base update review article on measurement, and 2 future directions review articles concerning outbursts, mood, dispositions, and youth psychopathology more broadly. By deliberatively investigating the affective side of disruptive behavior, we hope these articles will help bring about better understanding, assessment, and treatment of these challenging problems, for the benefit of youth and families.

Examining accurate diagnosis of complex PTSD in ICD-11

BACKGROUND

Complex posttraumatic stress disorder (complex PTSD), the most frequently suggested new category for inclusion by mental health professionals, has been included in the Eleventh Revision of the World Health Organization's International Classification of Diseases (ICD-11). Research has yet to explore whether clinicians' recognition of the distinct complex PTSD symptoms predicts giving the correct diagnosis. The present study sought to determine if international mental health professionals were able to accurately diagnose complex PTSD and identify the shared PTSD features and three essential diagnostic features, specific to complex PTSD.

METHODS

Participants were randomly assigned to view two vignettes and tasked with providing a diagnosis (or indicating that no diagnosis was warranted). Participants then answered a series of questions regarding the presence or absence of each of the essential diagnostic features specific to the diagnosis they provided.

RESULTS

Clinicians who recognized the presence or absence of complex PTSD specific features were more likely to arrive at the correct diagnostic conclusion. Complex PTSD specific features were significant predictors while the shared PTSD features were not, indicating that attending to each of the specific symptoms was necessary for diagnostic accuracy of complex PTSD.

LIMITATIONS

The use of written case vignettes including only adult patients and a non-representative sample of mental health professionals may limit the generalizability of the results.

CONCLUSIONS

Findings support mental health professionals' ability to accurately identify specific features of complex PTSD. Future work should assess whether mental health providers can effectively identify symptoms of complex PTSD in a clinical setting.

Is respiratory sinus arrhythmia a modifiable index of symptom change in cognitive behavioral therapy for youth? A pooled-data analysis of a randomized trial

OBJECTIVE

We evaluated whether respiratory sinus arrhythmia (RSA) reactivity and resting RSA-physiological markers reflecting the increase in heart rate with inspiration and decrease during expiration related to parasympathetic influence on the heart-are modifiable and predict symptom change during youth psychotherapy. Methods: Diverse youth (N = 158; ages 7-15; 48.1% female) received the Modular Approach to Therapy for Children and completed pre-treatment (pre), post-treatment (post), and 18-months postbaseline (18Mo) assessments. We measured resting RSA, RSA reactivity during stress induction, and psychopathology symptoms. Results: Pre-to-post and pre-to-18Mo, reactivity decreased, and resting RSA increased. Changes in reactivity and resting RSA, separately, did not predict reduced psychopathology. Yet, decreased reactivity combined with increased resting RSA predicted reduced psychopathology over time, suggesting that observed RSA changes were beneficial for some. Higher dosage of a module utilizing slow-breathing, muscle-relaxation, and imagery predicted greater pre-to-18Mo changes in reactivity and resting RSA, whereas a similar module with less emphasis on slow-breathing did not. Conclusions: Findings raise the possibility that youth reactivity and resting RSA could be modifiable during cognitive behavioral therapy and contribute to the amelioration of psychopathology. More studies are needed to determine whether resting RSA and RSA reactivity are modifiable indices of symptom change in slow-breathing practices and psychotherapy.

CLINICALTRIALS.GOV IDENTIFIER

NCT03153904, registered May 15, 2017.

Daily Associations Between Sleep and Affect in Youth at Risk for Psychopathology: The Moderating Role of Externalizing Symptoms

Problems with sleep, emotion regulation, and externalizing psychopathology are interrelated, but little is known about their day-to-day associations in youth. We examined self-reported daily sleep quality as a bidirectional predictor of next-day positive and negative affect (PA/NA), with externalizing symptoms as a moderator. Data were drawn from an ecological momentary assessment (EMA) study involving 82 youths (ages 9-13; 50% female; 44% White, 37% Black/African American) at high (n = 41) or low (n = 41) familial risk for psychopathology. Parents rated youths' externalizing symptoms at baseline. Youths then completed a 9-day EMA protocol, reporting sleep quality 1x/day and affect 4-8x/day. Daily means, peaks, and variability in PA and NA were computed. Multilevel models examined bidirectional associations between sleep and affect (between- and within-person), testing externalizing symptoms as a moderator and controlling for age and sex. In models of sleep predicting affect: Within-person, poorer-than-usual sleep quality predicted greater variability and higher peaks in next-day NA, but only for youth with higher levels of externalizing symptoms. Between-person, poor sleep quality and higher levels of externalizing symptoms predicted lower mean and peak PA. In models of affect predicting sleep: Within-person, lower-than-usual mean PA predicted poorer subsequent sleep quality, but only for youth with higher levels of externalizing symptoms. Between-person, youths with higher mean and peak PA had better sleep quality. These findings suggest that affective functioning is bidirectionally linked to daily self-reported sleep quality among high- and low-risk youth. Specific disturbances in daily sleep-affect cycles may be distinctly associated with externalizing psychopathology.

Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): study protocol for a randomized controlled effectiveness trial in outpatient clinics

BACKGROUND

Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST-a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change-regulation of negative emotions; and (3) explore variables that may influence clinicians' treatment implementation.

METHODS

This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7-15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.

DISCUSSION

This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.

TRIAL REGISTRATION

NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT04725721.

Toward greater specificity in the nonspecific: Estimating the prevalence of diagnostic irritability and sleep symptoms in adolescents

The Diagnostic and Statistical Manual of Mental Disorders (DSM) descriptive criterial approach to diagnosis has been criticized for contributing to comorbidity, heterogeneity within conditions, and nonspecificity across conditions. Much research has examined comorbidity and heterogeneity, but less is known about nonspecificity. Here, we examined two nonspecific symptoms: irritability and sleep disturbance. Both are common, clinically significant, and appear in several DSM disorder criteria sets, but their transdiagnostic prevalence is unknown. Leveraging a nationally representative epidemiological study of adolescents (n = 10,148; ages = 13-18), we first identified all instances where irritability or sleep disturbance appears in DSM-5-TR criteria for bipolar, depressive, anxiety, traumatic stress, or disruptive/impulse-control disorders; then found their DSM-IV equivalents in study variables; and finally estimated their prevalence individually and cumulatively across categories. Weighted lifetime prevalence estimates were 79.5% (95% CI [77.8, 81.2]) for irritability and 60.8% [58.7, 62.9] for sleep disturbance. Associations with age and gender were significant but small. Most youth reported multiple symptoms of irritability (weighted M = 3.04, Mdn = 2) and at least one symptom of sleep disturbance (weighted M = 1.61, Mdn = 1). Both problems were extremely common among individuals with specific disorders but were underestimated by the criteria for those conditions. Results suggest that the high prevalence of DSM-defined irritability and sleep problems may be obfuscated by these symptoms being scattered across diagnostic entities. There is a need for more research on assessing, treating, and understanding problems related to irritability and sleep in their own right, cutting across, rather than confined to, particular diagnoses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): Study Protocol for a Randomized Controlled Effectiveness Trial in Outpatient Clinics

Background

Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST-a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change-regulation of negative emotions; and (3) explore variables that may influence clinicians' treatment implementation.

Methods

This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7-15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.

Discussion

This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.

Trial registration

NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT04725721.

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.

Finding a Needed Diagnostic Home for Children with Impulsive Aggression

Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.

Editorial: Roads Less Traveled: New Directions for Novel Outcomes in Youth Irritability Research

Road metaphors are ubiquitous in youth mental health. Developmental psychopathology research is described in terms of pathways, trajectories, cascades, and transitions. Children's behavioral concerns are discussed as warning signs and rough spots. Although these metaphors have long been useful abstractions, modern quantitative methods and large-scale longitudinal studies have made it possible to empirically investigate the "roads" traveled by individuals across development. One goal here is to chart the paths most often followed by different subgroups of youth. Another goal involves surveying variables that nudge children toward (or away from) psychopathology and other key outcomes. These 2 goals-finding trajectories and predictors thereof-have important implications for research, intervention, and policy; and some of the most important studies, in our view, accomplish both.

Predictors of Dissertation Publication in Clinical and Counseling Psychology

A doctoral dissertation constitutes a student's original research and a novel contribution to scientific knowledge. Yet, few psychology dissertations, particularly in professional subfields, are published in the peer-reviewed literature, and the reasons for this are unclear. The present study investigated student, advisor, and doctoral program variables that might predict dissertation publication in professional psychology. Using a stratified random cohort sample of 169 Ph.D. dissertations in clinical and counseling psychology, we conducted exhaustive searches to determine whether dissertation studies were published in peer-reviewed journals within 0-7 years following their completion. Logistic regression models were estimated to test whether dissertation publication was predicted by student and advisor prior research productivity, dissertation length, and doctoral program's training emphasis, accreditation status, and subfield. Results indicated that dissertations that were supervised by more research-productive advisors and that were relatively brief (<180 pages) were significantly more likely to be published in peer-reviewed journals. No other predictors were significant. Results are discussed with regard to implications for training and mentorship. Faculty advisors who publish frequently might be more likely to attract research-oriented students, to mentor students in preparing a publishable dissertation, and/or to encourage students to publish their dissertation research. By systematically promoting research dissemination as part of doctoral research training, graduate programs and faculty mentors in clinical and counseling psychology could help facilitate students' sharing their dissertation findings with the scientific community.

Debate: Oppositional defiant disorder is a real disorder

Oppositional defiant disorder (ODD) is a valid mental health disorder, characterized by negativistic defiant behavior and angry, irritable mood. The very low and stable prevalence rate over development from early childhood into adulthood suggests that ODD does not erroneously medicalize normative childhood behavior. ODD is associated with significant impairments across multiple contexts and raises risks for other future psychopathology. Although simplistic tropes often suggest that ODD is merely the product of bad parenting, substantial evidence shows that it is instead influenced by a variety of factors, including genetic and neurobiological factors. Individuals with ODD evoke negative interactions with peers, teachers, coworkers, romantic partners, and parents. ODD is often misunderstood as being a mild form of conduct disorder (CD). Rather, in stark contrast to ODD, CD reflects a pattern of aggressive behaviors, violations of laws or status offenses, and psychopathic features. Mounting evidence for their distinction led to diagnostic changes distinguishing ODD and CD nearly a decade ago. Empirically supported treatments are available and help caregivers to develop specific parenting practices to meet the needs of children with ODD. Minimizing and mischaracterizing ODD increases the likelihood that families who are suffering may not seek the treatment that they need.

Whose Outcomes Come Out? Patterns of Caregiver- and Youth-reported Outcomes Based on Caregiver-youth Baseline Discrepancies

OBJECTIVE

Discrepancies between caregiver and youth reports of emotional and behavioral symptoms are well-documented, with cross-informant correlations often falling in the low to moderate range. Studies have shown that caregiver-youth (dis)agreement in reporting of youth symptoms is related to treatment outcomes. However, commonly used methods for exploring reporter discrepancies (e.g., difference scores) are limited by their inability to assess discrepancies across multiple symptom domains simultaneously, and thus these previous findings do not explore multiple patterns of (dis)agreement.

METHOD

We used latent profile analysis (LPA) to identify subgroups of clinically referred youths based on patterns of caregiver- and youth-reported internalizing and externalizing symptoms for 174 caregiver-youth dyads. Longitudinal multilevel models were used to examine changes in weekly caregiver- and youth-reported internalizing symptoms, externalizing symptoms, and top problems for identified subgroups.

RESULTS

The LPA identified four latent subgroups: (a) Caregiver Internalizing (9%), (b) Caregiver Internalizing-Externalizing (45%), (c) Youth Internalizing (7%), and (d) Caregiver-Youth Internalizing-Externalizing (39%). Clinical outcomes varied across informants and subgroups. Significant improvements in caregiver- and youth-reported outcome measures were documented within the Caregiver Internalizing, Caregiver Internalizing-Externalizing, and Caregiver-Youth Internalizing-Externalizing subgroups. However, only youth-reported improvements were detected in the Youth Internalizing subgroup. The results show differences in treatment outcomes across caregiver-youth informant subgroups.

CONCLUSIONS

These findings suggest how youth and caregiver baseline data could provide guidance for clinicians in interpreting discrepant reporting and its relevance to change during treatment.

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

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

Can Clinicians Use Dimensional Information to Make a Categorical Diagnosis of Paraphilic Disorders? An ICD-11 Field Study

BACKGROUND

The diagnosis of paraphilic disorder is a complicated clinical judgment based on the integration of information from multiple dimensions to arrive at a categorical (present/absent) conclusion. The recent update of the guidelines for paraphilic disorders in ICD-11 presents an opportunity to investigate how mental health professionals use the diagnostic guidelines to arrive at a diagnosis which thereby can optimize the guidelines for clinical use.

AIM

This study examined clinicians' ability to use the ICD-11 diagnostic guidelines for paraphilic disorders which contain multiple dimensions that must be simultaneously assessed to arrive at a diagnosis.

METHODS

The study investigated the ability of 1,263 international clinicians to identify the dimensions of paraphilic disorder in the context of written case vignettes that varied on a single dimension only.

OUTCOMES

Participants provided diagnoses for the case vignettes along with dimensional ratings of the degree of presence of five dimensions of paraphilic disorder (arousal, consent, action, distress, and risk).

RESULTS

Across a series of analyses, clinicians demonstrated a clear ability to recognize and appropriately integrate the dimensions of paraphilic disorders; however, there was some evidence that clinicians may over-diagnose non-pathological cases.

CLINICAL TRANSLATION

Clinicians would likely benefit from targeted training on the ICD-11 definition of paraphilic disorder and should be cautious of over-diagnosing.

STRENGTHS AND LIMITATIONS

This study represents a large international sample of health professionals and is the first to examine clinicians' ability to apply the ICD-11 diagnostic guidelines for paraphilic disorders. Important limitations include not generalizing to all clinicians and acknowledging that results may be different in direct clinical interactions vs written case vignettes.

CONCLUSION

These results indicate that clinicians appear capable of interpreting and implementing the diagnostic guidelines for paraphilic disorders in ICD-11.

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

Severe irritability is common in treatment-referred youth, often occurring in externalizing, anxiety, and mood conditions. The best available evidence indicates behavioral parent training and cognitive-behavioral therapy as first-line interventions. Modular approaches (eg, MATCH) can package these strategies in a flexible format, facilitating personalization. Ample evidence supports MATCH's effectiveness generally and initial evidence supports its effectiveness for irritability specifically. We provide an overview of MATCH and its application to severe irritability. Emphasis is placed on behavioral parent training as a likely primary/first-line treatment. Potential benefits and limitations are considered. This approach calls for careful clinical judgment and for further empirical research.

Clinician training, then what? Randomized clinical trial of child STEPs psychotherapy using lower-cost implementation supports with versus without expert consultation

OBJECTIVE

Implementation of evidence-based treatments in funded trials is often supported by expert case consultation for clinicians; this may be financially and logistically difficult in clinical practice. Might less costly implementation support produce acceptable treatment fidelity and clinical outcomes?

METHOD

To find out, we trained 42 community clinicians from four community clinics in Modular Approach to Therapy for Children (MATCH), then randomly assigned them to receive multiple lower-cost implementation supports (LC) or expert MATCH consultation plus lower-cost supports (CLC). Clinically referred youths (N = 200; ages 7-15 years, M = 10.73; 53.5% male; 32.5% White, 27.5% Black, 24.0% Latinx, 1.0% Asian, 13.5% multiracial, 1.5% other) were randomly assigned to LC (n = 101) or CLC (n = 99) clinicians, and groups were compared on MATCH adherence and competence, as well as on multiple clinical outcomes using standardized measures (e.g., Child Behavior Checklist, Youth Self-Report) and idiographic problem ratings (Top Problems Assessment).

RESULTS

Coding of therapy sessions revealed substantial therapist adherence to MATCH in both conditions, with significantly stronger adherence in CLC; however, LC and CLC did not differ significantly in MATCH competence. Trajectories of change on all outcome measures were steep, positive, and highly similar for LC and CLC youths, with no significant differences; a supplemental analysis of posttreatment outcomes also showed similar LC and CLC posttreatment scores, with most LC-CLC differences nonsignificant.

CONCLUSIONS

The findings suggest that effective implementation of a complex intervention in clinical practice may be supported by procedures that are less costly and logistically challenging than expert consultation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Modular Psychotherapy Outcomes for Youth With Different Latent Profiles of Irritability and Emotion Dysregulation

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.

Evaluating a Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems (MATCH) in School-Based Mental Health Care: Study Protocol for a Randomized Controlled Trial

Introduction: Schools have become a primary setting for providing mental health care to youths in the U.S. School-based interventions have proliferated, but their effects on mental health and academic outcomes remain understudied. In this study we will implement and evaluate the effects of a flexible multidiagnostic treatment called Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) on students' mental health and academic outcomes.

Methods and Analysis: This is an assessor-blind randomized controlled effectiveness trial conducted across five school districts. School clinicians are randomized to either MATCH or usual care (UC) treatment conditions. The target sample includes 168 youths (ages 7–14) referred for mental health services and presenting with elevated symptoms of anxiety, depression, trauma, and/or conduct problems. Clinicians randomly assigned to MATCH or UC treat the youths who are assigned to them through normal school referral procedures. The project will evaluate the effectiveness of MATCH compared to UC on youths' mental health and school related outcomes and assess whether changes in school outcomes are mediated by changes in youth mental health.

Ethics and Dissemination: This study was approved by the Harvard University Institutional Review Board (IRB14-3365). We plan to publish the findings in peer-reviewed journals and present them at academic conferences.

Clinical Trial Registration:ClinicalTrials.gov ID: NCT02877875. Registered on August 24, 2016.

Diagnostic classification of irritability and oppositionality in youth: a global field study comparing ICD-11 with ICD-10 and DSM-5

BACKGROUND

Severe irritability has become an important topic in child and adolescent mental health. Based on the available evidence and on public health considerations, WHO classified chronic irritability within oppositional defiant disorder (ODD) in ICD-11, a solution markedly different from DSM-5's (i.e. the new childhood mood diagnosis, disruptive mood dysregulation disorder [DMDD]) and from ICD-10's (i.e. ODD as one of several conduct disorders without attention to irritability). In this study, we tested the accuracy with which a global, multilingual, multidisciplinary sample of clinicians were able to use the ICD-11 classification of chronic irritability and oppositionality as compared to the ICD-10 and DSM-5 approaches.

METHODS

Clinicians (N = 196) from 48 countries participated in an Internet-based field study in English, Spanish, or Japanese and were randomized to review and use one of the three diagnostic systems. Through experimental manipulation of validated clinical vignettes, we evaluated how well clinicians in each condition could identify chronic irritability versus nonirritable oppositionality, episodic bipolar disorder, dysthymic depression, and normative irritability.

RESULTS

Compared to ICD-10 and DSM-5, ICD-11 led to more accurate identification of severe irritability and better differentiation from boundary presentations. Participants using DSM-5 largely failed to apply the DMDD diagnosis when it was appropriate, and they more often applied psychopathological diagnoses to developmentally normative irritability.

CONCLUSIONS

The formulation of irritability and oppositionality put forth in ICD-11 shows evidence of clinical utility, supporting accurate diagnosis. Global mental health clinicians can readily identify ODD both with and without chronic irritability.

Taxonomy and utility in the diagnostic classification of mental disorders

OBJECTIVE

One strategy for improving the clinical utility of mental health diagnostic systems is to better align them with how clinicians conceptualize psychopathology in practice. This approach was used in International Classification of Diseases 11th Revision (ICD-11) development, but its underlying assumption-a link between taxonomic "fit" and clinical utility-remains untested.

METHODS

Using data from global mental health clinician samples (combined N = 5404), we investigated the association between taxonomic fit and clinical utility in mental disorder categories.

RESULTS

The overall association between fit and utility was positive (r = 0.19) but statistically not different from zero (95% confidence interval [CI]: -0.06, 0.43) in this small sample (N = 39 ICD/DSM categories). However, a positive association became clear after correcting for outliers (r = 0.34 [0.05, 0.58] or higher). Further insights were apparent for specific diagnoses given their locations in the scatterplot.

CONCLUSIONS

Results suggest a positive link between taxonomic fit and clinical utility in mental disorder diagnoses, highlighting future research directions.

An organization- and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Parallel Trajectories of Proactive and Reactive Aggression in Middle Childhood and Their Outcomes in Early Adolescence

This study used an accelerated longitudinal design to investigate trajectories of proactive and reactive aggression in middle childhood and their outcomes in early adolescence. Children (N = 1420; ages 5-12; 48% female) were assessed biannually over 6 school years. Classroom teachers rated students' proactive and reactive aggression throughout grades K-5; and multi-method (teacher-report, self-report, school records) measures of peer problems, depressive symptoms, academic performance, disciplinary actions, and school absenteeism were collected throughout grades 3-5. Latent class growth models were estimated to differentiate parallel-process trajectories of proactive-reactive aggression. Class membership was then examined as a predictor of outcomes at the end of 5th grade. The best-fitting solution had four trajectory classes: (1) low aggression, 76.7%; (2) high proactive-reactive aggression, 4.7%; (3) declining aggression, 4.9%; and (4) predominantly reactive aggression, 13.7%. Most classes showed seasonal upticks in aggressive behavior in the spring semester relative to fall; these were especially pronounced for proactive aggression, both as a variable and for the proactive-reactive class. Relative to their low-aggression peers, children in any elevated-aggression class had higher levels of peer problems, depressive symptoms, and disciplinary actions and lower GPAs at the end of 5th grade. The reactive class-which on no occasion had the highest total aggression-exhibited the most consistently unfavorable pattern of outcomes across methods and measures. Findings offer new insights concerning the multifinality and heterogeneity of aggressive behavior in childhood. Research, theory, and practice could benefit from adopting person-centered conceptualizations that consider the long-term trajectories, short-term variations, and proactive vs. reactive functions of youth aggression.

Effects of standard and modular psychotherapies in the treatment of youth with severe irritability

OBJECTIVE

To examine the preliminary effectiveness of a modular, transdiagnostic, behavioral/cognitive-behavioral intervention (MATCH) compared with standard manualized treatments (SMT) and usual care (UC) for treating youth with severe irritability.

METHOD

We analyzed data from an effectiveness trial in which treatment-referred youths (N = 174; M_age = 10.6 years; 70% boys) were randomized to receive MATCH, SMT, or UC (ns = 53-62). Masked assessments of irritability, diagnoses, impairment, and internalizing, externalizing, total, and top problems were collected from caregivers and youths at pre- and posttreatment, weekly during treatment, and quarterly through 2-year follow-up. Baseline measures of irritability and impairment were used to identify a subsample characterized by severe irritability and mood dysregulation (SIMD; n = 81; M_age = 10.2 years; 69% boys; ns = 24-31 across conditions). Longitudinal multilevel models and ANOVAs were estimated to examine numerous clinical outcomes within and between conditions.

RESULTS

Among youth with SIMD, MATCH produced faster improvements than UC and SMT, with medium or large effect sizes in two thirds of all comparisons tested (Mdn ES = 0.60). Although SIMD youths in all conditions showed reductions in DSM diagnoses, only MATCH predicted significantly fewer posttreatment diagnoses than UC (averaging 1.0 fewer; ES = 0.93). Finally, among the entire sample, MATCH and SMT equivalently outperformed UC in reducing irritability (ES = 0.49) and the effects of each treatment condition on other outcomes were not moderated by baseline irritability.

CONCLUSIONS

Extant behavioral/cognitive-behavioral psychotherapies-already well-established and widely used-may be helpful for treating youths with severe irritability. A transdiagnostic, modular format showed the most consistently favorable pattern of results across multiple outcomes, informants, and measurement schedules. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention

Severe irritability is a common and clinically important problem longitudinally associated with internalizing and externalizing problems in children. To better understand these mechanisms and to inform treatment research, we tested cognitive-behavioral processes as candidate mediators in the paths from irritability to later problems. Methods: A school sample (N = 238, 48% female, ages 8-10) was assessed at ~6-month intervals in fall (T1) and spring (T2) of third to fourth grade, and again the following fall (T3). Measures assessed irritability (T1/predictor); anger and sadness coping, intolerance of uncertainty, and rumination; (T1-T2/mediators); and anxiety, depressive symptoms, reactive aggression, and oppositionality (T1-T3/outcomes). Focused cross-lagged panel models, controlling for gender and grade, were specified to examine full (X_T1 ➔ M_T2 ➔ Y_T3) and half (X_T1 ➔ M_T2; M_T1 ➔ Y_T2) longitudinal mediation. Across one or more intervals, irritability predicted higher depressive symptoms, anxiety, reactive aggression, oppositionality, intolerance of uncertainty, and poor emotion coping. From T1 irritability to T2/T3 outcomes, mediation was found for poor sadness coping leading to reactive aggression and oppositionality; poor anger coping to anxiety, depressive symptoms, and oppositionality; and intolerance of uncertainty to anxiety. Results offer further evidence for internalizing and externalizing outcomes of youth irritability and new evidence suggesting underlying mechanisms. Irritability may confer risk for externalizing problems via poor sadness/anger coping, and for internalizing problems via poor anger coping and intolerance of uncertainty. Theoretical models and psychosocial treatment should consider addressing regulation of various unpleasant emotions as well as psychological flexibility and tolerating uncertainty.

Sex/Gender Differences in Screening for Autism Spectrum Disorder: Implications for Evidence-Based Assessment

Autism spectrum disorder (ASD) is diagnosed more often in boys than in girls; however, little is known about the nature of this sex/gender discrepancy or how it relates to diagnostic assessment practices. This study examined the performance of the Social Communication Questionnaire (SCQ) in screening for ASD among boys and girls. Data were drawn from the South Carolina Children's Educational Surveillance Study, a population-based study of ASD prevalence among children 8-10 years of age. Analyses were conducted using SCQ data from 3,520 children, with direct assessment data from 272 with elevated SCQ scores. A bifactor model based on the Diagnostic and Statistical Manual of Mental Disorders's (5th ed.) two ASD symptom domains fit the data well and performed slightly better for girls. In the general population sample, girls exhibited fewer social communication/interaction and restricted-repetitive behavior symptoms than boys. In the direct assessment sample, however, girls with ASD showed greater impairment in social communication/interaction than boys with ASD. Items pertaining to social communication/interaction problems at ages 4-5 were among the most diagnostically efficient overall and particularly for girls. Similarly, receiver operating characteristic analyses suggested that the SCQ performs adequately among boys and well among girls. Results support the use of the SCQ in screening for ASD but do not indicate sex/gender-specific cutoffs. Girls with ASD may exhibit pronounced intraindividual deficits in social communication/interaction compared to male peers with ASD and female peers without ASD. Although more research is needed, careful attention to social communication/interaction deficits around 4-5 years of age may be especially useful for assessing ASD in girls.

Testing Robustness of Child STEPs Effects with Children and Adolescents: A Randomized Controlled Effectiveness Trial

A critical task in psychotherapy research is identifying the conditions within which treatment benefits can be replicated and outside of which those benefits are reduced. We tested the robustness of beneficial effects found in two previous trials of the modular Child STEPs treatment program for youth anxiety, depression, trauma, and conduct problems. We conducted a randomized trial, with two significant methodological changes from previous trials: (a) shifting from cluster- to person-level randomization, and (b) shifting from individual to more clinically feasible group-based consultation with STEPs therapists. Fifty community clinicians from multiple outpatient clinics were randomly assigned to receive training and consultation in STEPs (n= 25) or to provide usual care (UC; n= 25). There were 156 referred youths-ages 6-16 (M= 10.52, SD = 2.53); 48.1% male; 79.5% Caucasian, 12.8% multiracial, 4.5% Black, 1.9% Latino, 1.3% Other-who were randomized to STEPs (n= 77) or UC (n= 79). Following previous STEPs trials, outcome measures included parent- and youth-reported internalizing, externalizing, total, and idiographic top problems, with repeated measures collected weekly during treatment and longer term over 2 years. Participants in both groups showed statistically significant improvement on all measures, leading to clinically meaningful problem reductions. However, in contrast to previous trials, STEPs was not superior to UC on any measure. As with virtually all treatments, the benefits of STEPs may depend on the conditions-for example, of study design and implementation support-in which it is tested. Identifying those conditions may help guide appropriate use of STEPs, and other treatments, in the future.

Examining ODD/ADHD Symptom Dimensions as Predictors of Social, Emotional, and Academic Trajectories in Middle Childhood

The goal of this article is to investigate the symptom dimensions of oppositional defiant disorder (ODD; irritability, defiance) and attention deficit/hyperactivity disorder (ADHD; inattention, hyperactivity-impulsivity) as predictors of academic performance, depressive symptoms, and peer functioning in middle childhood. Children (N = 346; 51% female) were assessed via teacher-report on measures of ODD/ADHD symptoms at baseline (Grades K-2) and academic performance, depressive symptoms, peer rejection, and victimization on 7 occasions over 4 school years (K-2 through 3-5). Self-report and grade point average data collected in Grades 3-5 served as converging outcome measures. Latent growth curve and multiple regression models were estimated using a hierarchical/sensitivity approach to assess robustness and specificity of effects. Irritability predicted higher baseline depressive symptoms, peer rejection, and victimization, whereas defiance predicted higher baseline peer rejection; however, none of these ODD-related effects persisted 3 years later to Grades 3-5. In contrast, inattention predicted persistently poorer academic performance, persistently higher depressive symptoms, and higher baseline victimization; hyperactivity-impulsivity predicted subsequent peer rejection and victimization in Grades 3-5. In converging models, only inattention emerged as a robust predictor of 3-year outcomes (viz., grade point average, depressive symptoms, peer rejection, and relational victimization). Broadly, ODD dimensions-particularly irritability-may be linked to acute disturbances in social-emotional functioning in school-age children, whereas ADHD dimensions may predict more persistent patterns of peer, affective, and academic problems. By examining all 4 ODD/ADHD symptom dimensions simultaneously, the present analyses offer clarity and specificity regarding which dimensions affect what outcomes, and when. Findings underscore the importance of multidimensional approaches to research, assessment, and intervention.

Assessing the Irritable and Defiant Dimensions of Youth Oppositional Behavior Using CBCL and YSR Items

Research suggests that irritability and defiance are distinct dimensions of youth oppositionality that are differentially associated with internalizing and conduct problems, respectively. Because much of this evidence has emerged with limited psychometric evaluation, we conducted the first multi-informant examination of selected Child Behavior Checklist (CBCL) and Youth Self Report (YSR) items for measuring irritability and defiance in a large clinical sample. Clinically referred youths (N = 1,030; ages 6-15; 43% female, 42% ethnic minority) were assessed prior to treatment using multi-informant rating scales and diagnostic interviews. Analyses examined factor structure, invariance, internal consistency, multi-informant patterns, and convergent, discriminant, and criterion validity with internalizing and externalizing problems/disorders. A correlated 2-factor model of irritability (stubborn/sullen/irritable, mood, temper) and defiance (argues, disobeys-home, disobeys-school) fit well for both informants. Adequate measurement invariance and scale consistency was consistently found for parent-report but not youth-report. With both informants, all hypothesized convergent and discriminant validity associations were supported: irritability and defiance with internalizing and conduct scales, respectively. However, hypothesized criterion validity associations were largely found only by parent-report: irritability with anxiety and depressive disorders, defiance with conduct disorder, and both with oppositional defiant disorder. Results consistently supported the reliability and validity of the CBCL irritability and defiance scales, with somewhat less consistent support for the YSR scales. Thus, CBCL items may provide psychometrically sound assessment of irritability and defiance, whereas further research is needed to advance youth-report and multi-informant strategies. Results also provide further support for a two subdimension model of oppositional defiant disorder symptoms that includes irritability and defiance.

The classification of feeding and eating disorders in the ICD-11: results of a field study comparing proposed ICD-11 guidelines with existing ICD-10 guidelines

BACKGROUND

The World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD) is used globally by 194 WHO member nations. It is used for assigning clinical diagnoses, providing the framework for reporting public health data, and to inform the organization and reimbursement of health services. Guided by overarching principles of increasing clinical utility and global applicability, the 11th revision of the ICD proposes major changes that incorporate empirical advances since the previous revision in 1992. To test recommended changes in the Mental, Behavioral, and Neurodevelopmental Disorders chapter, multiple vignette-based case-controlled field studies have been conducted which examine clinicians' ability to accurately and consistently use the new guidelines and assess their overall clinical utility. This manuscript reports on the results from the study of the proposed ICD-11 guidelines for feeding and eating disorders (FEDs).

METHOD

Participants were 2288 mental health professionals registered with WHO's Global Clinical Practice Network. The study was conducted in Chinese, English, French, Japanese, and Spanish. Clinicians were randomly assigned to apply either the ICD-11 or ICD-10 diagnostic guidelines for FEDs to a pair of case vignettes designed to test specific clinical questions. Clinicians selected the diagnosis they thought was correct for each vignette, evaluated the presence of each essential feature of the selected diagnosis, and the clinical utility of the diagnostic guidelines.

RESULTS

The proposed ICD-11 diagnostic guidelines significantly improved accuracy for all FEDs tested relative to ICD-10 and attained higher clinical utility ratings; similar results were obtained across all five languages. The inclusion of binge eating disorder and avoidant-restrictive food intake disorder reduced the use of residual diagnoses. Areas needing further refinement were identified.

CONCLUSIONS

The proposed ICD-11 diagnostic guidelines consistently outperformed ICD-10 in distinguishing cases of eating disorders and showed global applicability and appropriate clinical utility. These results suggest that the proposed ICD-11 guidelines for FEDs will help increase accuracy of public health data, improve clinical diagnosis, and enhance health service organization and provision. This is the first time in the revision of the ICD that data from large-scale, empirical research examining proposed guidelines is completed in time to inform the final diagnostic guidelines.

Efficient Monitoring of Treatment Response during Youth Psychotherapy: The Behavior and Feelings Survey

An emerging trend in youth psychotherapy is measurement-based care (MBC): treatment guided by frequent measurement of client response, with ongoing feedback to the treating clinician. MBC is especially needed for treatment that addresses internalizing and externalizing problems, which are common among treatment-seeking youths. A very brief measure is needed, for frequent administration, generating both youth- and caregiver-reports, meeting psychometric standards, and available at no cost. We developed such a measure to monitor youth response during psychotherapy for internalizing and externalizing problems. Across 4 studies, we used ethnically diverse, clinically relevant samples of caregivers and youths ages 7-15 to develop and test the Behavior and Feelings Survey (BFS). In Study 1, candidate items identified by outpatient youths and their caregivers were examined via an MTurk survey, with item response theory methods used to eliminate misfitting items. Studies 2-4 used separate clinical samples of youths and their caregivers to finalize the 12-item BFS (6 internalizing and 6 externalizing items), examine its psychometric properties, and assess its performance in monitoring progress during psychotherapy. The BFS showed robust factor structure, internal consistency, test-retest reliability, convergent and discriminant validity in relation to three well-established symptom measures, and slopes of change indicating efficacy in monitoring treatment progress during therapy. The BFS is a brief, free youth- and caregiver-report measure of internalizing and externalizing problems, with psychometric evidence supporting its use for MBC in clinical and research contexts.

Forms and Functions of Aggression in Early Childhood

Evidence supports the distinctions between forms (relational vs. physical) and functions (proactive vs. reactive) of aggression; however, little research has investigated these two subtype frameworks simultaneously or by teacher-report in early childhood. We examined the factor structures, interrelations, and longitudinal associations of teacher-reported forms and functions of aggression in young children. Preschool and kindergarten students (N = 133; ages 3-6 years; 58.6% male) were rated by their teachers during the spring semester and on two subsequent occasions over the following school year (a three-wave cross-sequential design). Bayesian confirmatory factor analyses and path models were estimated, controlling for covariates and cross-classification of students within classrooms. Correlated two-factor models showed acceptable measurement characteristics for both aggression frameworks. Within and between frameworks, aggression subtypes were highly correlated with one another. Physical aggression showed greater stability than, and was a precursor to, relational aggression, whereas both proactive and reactive aggression were stable and bidirectional. All subtypes-especially reactive and physical aggression-were robustly associated with peer rejection but not with academic performance or depressive symptoms. Results suggest that brief, teacher-reported rating scales can be used to measure forms and functions of aggression during early childhood. However, examination of one framework should elicit questions regarding the other (e.g., to what extent are measures of proactive and reactive aggression capturing physical aggression?), and research following a form-by-function approach may be particularly useful. Given their stability and outcomes, physical, reactive, and proactive aggression may be important targets for screening and intervention in early childhood settings.

A novel technique to optimise the length of a linear accelerator treatment room maze without compromising radiation protection

Simulations with the FLUktuierende KAskade (FLUKA) Monte Carlo code were used to establish the possibility of introducing lead to cover the existing concrete walls of a linear accelerator treatment room maze, in order to reduce the dose of the scattered photons at the maze entrance. In the present work, a pilot study performed at Singleton Hospital in Swansea was used to pioneer the use of lead sheets of various thicknesses to absorb scattered low energy photons in the maze. The dose reduction was considered to be due to the strong effect of the photoelectric interaction in lead resulting in attenuation of the back-scattered photons. Calculations using FLUKA with mono-energetic photons were used to represent the main components of the x-ray spectrum up to 10 MV. Mono-energetic photons were used to enable the study of the behaviour of each energy component from the associated interaction processes. The results showed that adding lead of 1 to 4 mm thickness to the walls and floor of the maze reduced the dose at the maze entrance by up to 80%. Subsequent scatter dose measurements performed at the maze entrance of an existing treatment room with lead sheet of 1.3 mm thickness added to the maze walls and floor supported the results from the simulations. The dose reduction at the maze entrance with the lead in place was up to 50%. The variation between simulation and measurement was attributed to the fact that insufficient lead was available to completely cover the maze walls and floor. This novel proposal of partly, or entirely, covering the maze walls with lead a few millimetres in thickness has implications for the design of linear accelerator treatment rooms since it has the potential to provide savings, in terms of space and costs, when an existing maze requires upgrading in an environment where space is limited and the maze length cannot be extended sufficiently to reduce the dose.

"Are you gonna publish that?" Peer-reviewed publication outcomes of doctoral dissertations in psychology

If a doctoral dissertation represents an original investigation that makes a contribution to one's field, then dissertation research could, and arguably should, be disseminated into the scientific literature. However, the extent and nature of dissertation publication remains largely unknown within psychology. The present study investigated the peer-reviewed publication outcomes of psychology dissertation research in the United States. Additionally, we examined publication lag, scientific impact, and variations across subfields. To investigate these questions, we first drew a stratified random cohort sample of 910 psychology Ph.D. dissertations from ProQuest Dissertations & Theses. Next, we conducted comprehensive literature searches for peer-reviewed journal articles derived from these dissertations published 0-7 years thereafter. Published dissertation articles were coded for their bibliographic details, citation rates, and journal impact metrics. Results showed that only one-quarter (25.6% [95% CI: 23.0, 28.4]) of dissertations were ultimately published in peer-reviewed journals, with significant variations across subfields (range: 10.1 to 59.4%). Rates of dissertation publication were lower in professional/applied subfields (e.g., clinical, counseling) compared to research/academic subfields (e.g., experimental, cognitive). When dissertations were published, however, they often appeared in influential journals (e.g., Thomson Reuters Impact Factor M = 2.84 [2.45, 3.23], 5-year Impact Factor M = 3.49 [3.07, 3.90]) and were cited numerous times (Web of Science citations per year M = 3.65 [2.88, 4.42]). Publication typically occurred within 2-3 years after the dissertation year. Overall, these results indicate that the large majority of Ph.D. dissertation research in psychology does not get disseminated into the peer-reviewed literature. The non-publication of dissertation research appears to be a systemic problem affecting both research and training in psychology. Efforts to improve the quality and "publishability" of doctoral dissertation research could benefit psychological science on multiple fronts.

Self-Reported Time in Bed and Sleep Quality in Association with Internalizing and Externalizing Symptoms in School-Age Youth

This study investigated the relationship between self-reported time in bed and sleep quality in association with self-reported internalizing and externalizing symptoms in a sample of 285 elementary school students (52 % female) recruited from a rural Midwestern elementary school. Path models were used to estimate proposed associations, controlling for grade level and gender. Curvilinear associations were found between time in bed and anxiety, depressive symptoms, and irritability. Marginal curvilinear trends were found between time in bed and emotion dysregulation, reactive aggression, and proactive aggression. Sleep quality was negatively associated with anxiety, depressive symptoms, irritability, reactive aggression, and delinquency engagement. Gender and grade differences were found across models. Findings suggest that examining self-reported time in bed (both linear and quadratic) and sleep quality is important for understanding internalizing and externalizing symptoms associated with sleep in school-age youth. Incorporating self-reported sleep assessments into clinical practice and school-based evaluations may have implications for a child's adjustment.

Not re-inventing the wheel: the adaptive implementation of the meeting centres support programme in four European countries

OBJECTIVES

The implementation of new health services is a complex process. This study investigated the first phase of the adaptive implementation of the Dutch Meeting Centres Support Programme (MCSP) for people with dementia and their carers in three European countries (Italy, Poland, the UK) within the JPND-MEETINGDEM project. Anticipated and experienced factors influencing the implementation, and the efficacy of the implementation process, were investigated. Findings were compared with previous research in the Netherlands.

METHOD

A qualitative multiple case study design was applied. Checklist on anticipated facilitators and barriers to the implementation and semi-structured interview were completed by stakeholders, respectively at the end and at the beginning of the preparation phase.

RESULTS

Overall, few differences between countries were founded. Facilitators for all countries were: added value of MCSP matching needs of the target group, evidence of effectiveness of MCSP, enthusiasm of stakeholders. General barriers were: competition with existing care and welfare organizations and scarce funding. Some countries experienced improved collaborations, others had difficulties finding a socially integrated location for MCSP. The step-by-step implementation method proved efficacious.

CONCLUSION

These insights into factors influencing the implementation of MCSP in three European countries and the efficacy of the step-by-step preparation may aid further implementation of MCSP in Europe.

Advancing the Scientific Foundation for Evidence-Based Practice in Clinical Child and Adolescent Psychology

Evidence-based practice (EBP) has become a central focus in clinical child and adolescent psychology. As originally defined, EBP in psychology is the integration of the best available research evidence, patient characteristics, and clinical expertise. Although evidence-based perspectives have garnered widespread acceptance in recent years, there has also been some confusion and disagreement about the 3-part definition of EBP, particularly the role of research. In this article, we first provide a brief review of the development of EBP in clinical child and adolescent psychology. Next, we outline the following 4 points to help clarify the understanding of EBP: (a) knowledge should not be confused with epistemic processes, (b) research on clinician and client factors is needed for EBP, (c) research on assessment is needed for EBP, and (d) the 3-part conceptualization of EBP can serve as a useful framework to guide research. Based on these principles, we put forth a slightly revised conceptualization of EBP, in which the role of research is expanded and more clearly operationalized. Finally, based on our review of the literature, we offer illustrative examples of specific directions for future research to advance the evidence base for EBP in clinical child and adolescent psychology.

Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.

Developing a science of clinical utility in diagnostic classification systems field study strategies for ICD-11 mental and behavioral disorders

The World Health Organization (WHO) Department of Mental Health and Substance Abuse has developed a systematic program of field studies to evaluate and improve the clinical utility of the proposed diagnostic guidelines for mental and behavioral disorders in the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11). The clinical utility of a diagnostic classification is critical to its function as the interface between health encounters and health information, and to making the ICD-11 be a more effective tool for helping the WHO's 194 member countries, including the United States, reduce the global disease burden of mental disorders. This article describes the WHO's efforts to develop a science of clinical utility in regard to one of the two major classification systems for mental disorders. We present the rationale and methodologies for an integrated and complementary set of field study strategies, including large international surveys, formative field studies of the structure of clinicians' conceptualization of mental disorders, case-controlled field studies using experimental methodologies to evaluate the impact of proposed changes to the diagnostic guidelines on clinicians' diagnostic decision making, and ecological implementation field studies of clinical utility in the global settings in which the guidelines will ultimately be implemented. The results of these studies have already been used in making decisions about the structure and content of ICD-11. If clinical utility is indeed among the highest aims of diagnostic systems for mental disorders, as their developers routinely claim, future revision efforts should continue to build on these efforts. (PsycINFO Database Record

International education and training for clinical child and adolescent psychology

Psychological problems in youth and adequate mental health service delivery to children, adolescents, and families are critical public health dilemmas around the world. Central to effectively addressing the mental health needs of youth and families is focusing attention on the evaluation and development of specialized training programs in clinical child and adolescent psychology. All countries to more or less degree face challenges, but lower-income countries have additional limitations (e.g., scarce resources for training, high demand for services, cultural barriers) to establishing clinical psychology programs and specialized services for children and adolescents. This article discusses the status of efforts in the United States to define clinical child and adolescent psychology and develop standard training recommendations for mental health providers who work with youth and families, international considerations for intervention implementation and training, and future directions in the field of clinical child and adolescent psychology.

The Role of Reactive Aggression in the Link Between Hyperactive-Impulsive Behaviors and Peer Rejection in Adolescents

Attention-deficit/hyperactivity disorder (ADHD) symptoms and aggressive behaviors are both associated with peer rejection, but little is known the nature of this association with respect to the two symptom dimensions of hyperactivity-impulsivity and inattention and different types of aggression. The present study examines the relations between dimensions of ADHD symptomatology, proactive and reactive aggression, and peer rejection in adolescence. Teacher-reported data were obtained for 200 high school students (grades 9-12; 48% female; predominately Latino). In structural equation modeling path analyses, the indirect effects of reactive aggression accounted for the link between hyperactivity-impulsivity and peer rejection. Within the same model, neither inattention nor proactive aggression were associated with peer rejection. These findings suggest that reactive aggression may be a key mechanism through which hyperactive-impulsive behavior is associated with peer rejection. Future research and intervention efforts should address the role of reactive aggression among youth with ADHD symptomatology.