with Gabrielle A. Carlson, MD, Robert R. Althoff, MD, PhD, Michael T. Sorter, MD

 

When Gabrielle A. Carlson, MD, took over as president of AACAP in 2019, she selected emotional dysregulation as the subject of her presidential initiative. Since then, the AACAP Presidential Initiative Task Force on Emotion Dysregulation in Children and Adolescents has been working to characterize children and adolescents with severe emotional dysregulation and outbursts and to identify treatment options. Of note, Dr. Carlson also serves as a professor of psychiatry and pediatrics at Stony Brook University School of Medicine in New York.

Agitation, irritability, explosive outbursts, and aggression frequently characterize children coming to care and represent some of the most common reasons for admission to inpatient treatment. Persistent outbursts of dysregulated emotion may lead to a disabling condition for children and adolescents. Unfortunately, there are limited evidence-based models for care and too few guidelines on the treatment of dysregulation, aggression, and violence in this patient population.

“What this means is that you can’t get appropriate treatment unless you can code and classify the disorder,” said Dr. Carlson in a post-conference 2020 interview with PsyCom Pro. “We don’t have a diagnosis that adequately captures emotional dysregulation and its frequency and severity, as well as how often it is comorbid with other diagnoses, such as ADHD.”

Defining an Outburst

The goals of AACAP’s Presidential Initiative include improving the diagnosis, prediction, measurement, and treatment of children and adolescents with severe outbursts, who are often referred to inpatient and outpatient treatment and are managed in emergency and residential settings. In her presentation, Phenomenology and How Data Guide Measures, Dr. Carlson gave an early report on the Task Force’s efforts to define dysregulation and how to measure it as part of the 2020 virtual conference.

She shared results of a survey of AACAP members and other psychiatric professionals which revealed that most prefer the term “outburst” (versus tantrum, meltdown, or mood swing) to describe explosive behaviors. Respondents also expressed a need for establishing ways to code outbursts for diagnostic purposes.

The frequency of outbursts and their degree of irritability are important measures, but data on the cause of impairments in children with explosive behavior revealed that the degree of aggression was the most important measure, shared Dr. Carlson. Parents of children who are aggressive toward property or persons are two to three times more likely to seek outpatient or inpatient treatment than parents of irritable children whose outbursts are frequent but merely verbal.

“The bottom line is that outbursts/meltdowns or whatever we wish to call them consist of screaming, hitting, kicking, threatening, and throwing things; they have the symptoms of preschool tantrums and have a median duration of 30 to 45 minutes,” Dr. Carlson had shared in her 2019 address about the initiative.

Inpatient and Outpatient Distinctions

The “sickest kids” (inpatients) have more aggressive outbursts, which are more frequent and prolonged than outbursts in children in outpatient settings. “This is important because the interviews used in research do not quantify these behaviors…. Phenomenology and treatment studies do not use standardized measures to assess the degree of severity,” Dr. Carlson explained. “Therefore, assessment instruments vary in their categorization of irritability or aggression in children, and they often miss the mark in describing how long outbursts last and where they occur.”

Measuring Irritability and Aggression in Children and Adolescents

Robert R. Althoff, MD, PhD, of the University of Vermont, presented early thoughts from the Task Force’s measurement working group. Their first goal was to consider a method to supplement the way in which the clinician interviews a parent/patient to capture aggression. The second goal was to create a modular version of a questionnaire that would be useful in research to quantify outbursts and aggression.

The group concluded that the Affective Reactivity Index (ARI) was useful to cover irritability, but more aggressive behaviors were best captured through the Revised Modified Overt Aggression Scale (R-MOAS) in addition to the Kiddie Schedule for Affective Disorders and Schizophrenia/Disruptive Mood Dysregulation Disorder (K-SADS DMDD) screening questions to quantify outbursts. The group considered that additional modules to the ARI might be useful to capture the range of aggression.

Treatment Options Under Study for Emotional Dysregulation

Michael T. Sorter, MD, of Cincinnati Children’s Hospital Medical Center, updated practitioners on the perspective of the Presidential Task Force on the current state of knowledge regarding treatment approaches and the need for improved treatment options. In his 2020 AACAP presentation, Issues in Treatment of Dysregulation in Children and Adolescents, he said that Task Force members found little in the literature on the best treatment approaches for eliminating aggression and addressing emotional dysregulation. Studies with outcome measures that focus on reducing the use of seclusion and restraints or the use of medications in inpatients do not necessarily indicate a reduction in frequency or duration of outbursts, according to Dr. Sorter.

Some studies that do show positive changes include interventions such as behavioral programs, cognitive techniques to improve problem-solving, and efforts to enhance therapeutic relationships. Outpatient programs using similar approaches, but with the addition of parent-directed interventions, have also demonstrated efficacy.

According to Dr. Sorter, the group concluded that much work is needed to develop specific guidelines to treat emotional dysregulation in children and adolescents, including accompanying irritability and aggression. These findings were further endorsed by the survey respondents, who reported uncertainty as to the value of different kinds of psychosocial treatment and medications that have some, albeit not great, effectiveness.

In her presentation, Dr. Carlson concluded that before the professional mental health community can address effective treatments, a few things are needed:

  • a simple, clinically useful interview and severity measure of both irritability and outbursts, the latter of which could be used as an outcome measure
  • a way to code children with outbursts, and
  • a realistic appraisal of both the treatments currently available and those that are still needed.

When asked by Dr. Daniel P. Dickstein, of Brown University, during the question-and-answer session whether we can we figure out a way in the interim to use secondary data analyses to move the field forward, Dr. Carlson advised, “Providers should write in their chief complaint notes, ‘This child is being seen for outbursts.’” She told PsyCom Pro, “We need to measure aggression rates, in order to know the context of the condition that is causing them and then be able to treat them both effectively.”

Next steps include developing a code for the DSM-5, developing a severity rating scale, producing a research agenda, and designing a website for the AACAP for consumer education. Stay tuned!

 

Last Updated: Dec 1, 2020