Community Conversation Webinar Series: Is Your Kid Often Angry, Cranky, Irritable?

all right well let's get started thank you everyone for coming today we are so delighted that you're here um firstly uh I want to introduce myself my name is Dr ramari Herman and I'm a clinical psychologist here at the neuroscience and na Therapeutics unit working at the emotion and development branch of the NIMH um I do want to highlight that this is one of several talks that we will be providing to the community um in the community conversations webinar series um so I invite you to look out for other talks in the future um as they will be other ones for topics that are a little bit different um but probably would pique your interest another piece I did want to share with everyone I have a few slido um polls um so please um make sure to um you can use your phone there'll be a QR code for that so please participate in the polls um as well as we will share some resources uh through the chat function um as well so just to be clear today we're going to be talking about irritability and um I'm going to discuss a couple of pieces around what um irritability in youth looks like as well as talking about treatments before we get started I want to give first disclosure I have no conflicts to disclose all the research and the information I'm providing here um has been supported by the NIMH inur research program this presentation should not be considered medical advice for any specific person so please talk with your ha healthcare provider about the benefits and risks of any treatment as well as you can visit the FDA website for the latest warnings patient medication guidelines and any newly approved drugs so again this is not to be taken as medical advice thank you I want to start by getting a sense of who's here um just to see if there's any pieces I could potentially um kind of highlight for those individuals that are here um specifically um so feel free to put your phone up um to the QR code I hope everybody can see that and then kind of click if you're um sort of if these categories do not uh fit with you I apolog olizee if I didn't make an a Very ex inclusive list um there is the other category so I just want to see more L who's present today just want to give people a little bit of time to make sure they can participate if they choose to looking at those numbers and who's present excellent all right so it's looking like predominantly mental health care providers so welcome we'll be speaking with um you know potential colleagues then um caregivers as well um other I guess that could be a wide range of individuals again I said I could not make an exhaustive list um and then family members of CH of a child of irritability so yeah mental health provider healthcare provider and some researcher scientists we are at the N image um excellent old person with irritability as well as teacher Okay so we've got a little bit of everything okay good to know who's here thank you all right so I want to give you an outline of what we're going to be discussing today first I want to start with what is clinical irit ability um so getting to kind of like the uh the Crux of what most of you are probably here for what to understand and know what cinic cor irritability is then we're going to talk a little bit about treatments and interventions that are out there and then I want to introduce you to this really cool immune treatment that we've developed here one of the things I mainly do here um which is an exposure based therapy for irritability so let's start with the why um just to kind of give you some context in general irritability is one of the most common reasons that children are referred to um treatment um and there

are few effective treatments for children with irritability um developing interen is particularly important because of the added um DSM which is the diagnostic and statistical manual that most of us in particular I'm sure those mental health providers that are here very familiar with it's what we use to assess and diagnose children um and adults as well so DSM created um added a diagnosis of disruptive mood disregulation disorder um which is characterized by the type of irritability that I would be discussing and in order to address this um diagnosis uh essentially uh like the symptoms that could be seen in the dmdd so the disruptive mood disregulation disorder diagnosis um our team has developed a treatment um to help address the type of reability present in this disorder so let's start with a little case example just to highlight who our kiddos are so let's talk a little bit about Jun J so junior is a 9-year-old boy that presents to us uh in our Clinic he's had chronic grouchiness and irritability temper Outburst all his life so at age six uh junior was suspended from school because of his behaviors and was then subsequently diagnosed with attention deficit hyperactivity disorder so at that time he was also put on medications um but he continued to have chronic grouchiness and temper alpers when frustrated so they tended to be mostly verbal but sometimes physical and they occurred um about daily at home with parents and then weekly at school so despite all of this it seems like his grouchiness and his temporar was continue despite being in treatment um so much so that it was limiting his ability to function at school so he was diagnosed with disruptive mood disregulation disorder so that just kind of give you some context and to encapsulate what this could look like in children so let's talk a little bit about what is irritability particularly what is clinical irritability so irritability is the tendency to anger compared to similar peers their age um that can reach a pathological or clinical level so it's relative to the age of the child compared to other typically developing children there's two facets to your readability in general that we look at um particularly the emotional component and the behavioral component so the emotional component is this irritable mood sort of that grouchy crabby State um that can happen for most of the time and then the behavioral component of what we technically call temper Outburst so sort of this inability to stop themselves from doing um sort of uh these aggressive behaviors um when they get frustrated or when they get angry so as you can see here in the little image there's a child kind of throwing their toy out in anger and breaking it so again irritability would have both of these components how do we determine whether it's reaching a clinical level we look at three uh domains uh when we look at that we look at the frequency so children with severe irritability they get angry more often than most children um so they tend to get angry a lot over the week um they tend to stay angry for longer so say 30 minutes to an hour possibly a whole day they could be angry for and then the threshold so little things can get them upset compared to same age peers so you know sometimes what might be upsetting to uh a four-year-old right uh could be one thing but then you have a 13-year-old who's getting upset for something similar doesn't seem Bri um the other critical piece about clinical irritability when we think of Psychopathology or we think of of of symptoms that could potentially be um imper right we need to think about how it affects the child in terms of their ability to function so we think about it in multiple domains we think about the home the school or with peers um and in this case if we if we want to conceptualize the reability being at a clinical level we need to think about whether it's affecting multiple areas and one critical piece too is about the context right so obviously pyam is assessed based on the child's age their developmental level as well as cultural context is going to be really important so what is a temper alur I kind of gave you a snapshot of what that was so these are some images of what a temper alpers can look like right we see here junior sort of um sort of you know raising their arms in anger or throwing their desk around um and then we see a couple of their children seemly screaming or throwing themselves on the floor um so these are different types of behaviors that can be exhibited or manifested when a child is um in this state so I want to then use the D the

slido call as well to ask you again so what is it mild temper Outburst look like what are some behaviors that one could see let's start with mild a mild temper alpers okay yelling stumping pouting gr facial expression mild stomping feet frustrated angry face shutting down okay tell me what a moderate would look like refuser to follow instructions set heavy thighs I like sessing very okay good whining mm flashing out at others yelling and crying seems to be number one answers and then let's see what a severe look like shutting down something feet pouting hitting won't listen throwing objects yes breaking things excellent violent absolutely absolutely mhm disruptive hitting walls running away fighting Crossing arms was there aggression towards objects throwing things Landing doors okay excellent self injury mm definitely physical hurting throwing self to the ground making verbal threats has been there excellent okay so yeah I mean absolutely you can see how these very disruptive behaviors um Can manifest themselves when children are frustrated or angry and what a temper Outburst tends to look like right um want to give more chance for people to finish typing slamming doors excellent okay so I think everyone has a sense for what this looks like right whether you've seen it in others maybe not yourself some FS or youth you know what this looks like um so let's see how we did so let's talk about it now what is The Temper out there so mild snapping talking back mild arguing name calling these would be in the mild range yelling and screaming which was our most common answer that's in the moderate range so we consider that moderate for our group um verbal threats that was literally something that somebody um inputed um clenching fists racing arms to hit that's in a moderate range and throwing things down in Anger right I'm not necessarily the intent to destroy property but throwing them down in anger and then severe I think most of us had a sense for what severe would looked like using objects in a way to harm uh physical displays breaking belongings um punching kicking I'm thinking of vandalism destruction of property shoving slapping so you know I think you all had even a more exhaustive list but just giving you a sense for sort of Where The Temper hour sort of range is in terms of mild moderate and severe so now I want to give you um another slide of call I want to get a sense for what are some common anger or frustration triggers for kids um what are some things that usually make kids is angry or frustrated yeah the word no not getting their way yes lack of control unfairness folding laundry good one it'll be an example of that later um academic demands embarrassment not having a choice being told no chores removing items feeling ill or scared mhm fine for bed sensory overload perceived Injustice similar to unfairness right um removing privileges yes absolutely not getting their way getting off videos don't understand the homework thank you that's a really good one there too um not getting their way again but different limit setting confused perfectionism losing friend fights rivalries not heard emotion disregulation this is fantastic you're all very good excellent okay exactly jealousy good one so these are some of the things right that make kids angry um I think we're all aware of sort of what that looks like in the realm you know particular being told no setting those limits you know this perceived unjustice or unfairness um so that would be another one so transitions yes absolutely abolutely so we talk a lot about transitions as

well wanting a toy or problem sharing um right being not being able to share so I think you've got most of it there um so let's talk about task endurance deficit I like that one um technology restrictions again um so you'll see they're all here so let's go through them ourselves so you predicted of course limiting screens um children do not appreciate that um and then having to do homework particularly you know I saw confused so a homework that's confusing or maybe a little bit harder than the child is able to complete or doesn't understand um you know and then I saw transitions was a really big um common response so transitioning from going from screens a preferred activity to going into doing homework which is a nonpreferred activity so that would definitely be a trigger for most kids in terms of you know leading to some sort of manifestation of anger whether it is you know the temper Outburst obviously eating their vegetables we all have to but um some kids definitely would throw aention particularly if they were expecting pizza right so expectations not bad so if they wanted pizza or you know chicken nuggets um and you provide them with a plate looking like this you might get a temper Outburst um you know I think also of like restrictions for teenagers let's say on social media or any of that right so thinking about those pieces um obviously the your activities of daily living slash your routine so that's one of the things that I tend to assess when I ask about impairment talk to me about your mornings evening um and then I try to gauge from that what are those triggers like bedtime routine even washing their hair right go taking a shower what does that look like for you um yes having to share particular say with siblings whether is in both cases there's a screen wanting to share right fighting with siblings about sharing a toy or sharing screens that can get a little tricky and siblings are always uh complicate a little bit more of the system right in terms of how to respond and how to handle children who have U irritability having to do chores um as well um right having to play their instrument or practice uh you know whether it is soccer basketball or the flute or piano lessons um having to practice um and then you know sometimes at the grocery store not getting them the snacks they want or at the toy store if they want like all the toys you know and it's interesting even sometimes right with sports and their extracurriculars there are times when their team will win and the child will come to me and say yeah but they didn't pass me the ball enough right so it's really about their perspective so to the child it makes sense as to why they're angry so it's really about their perspective about what was the goal that I was trying to achieve that was blocked what was my expectation right change to what was actually delivered um you know what did I actually want to do being told no right what was the no in this situation um so those are some common triggers that we see often with the kids that come to our studies so there's that second component right we just talked about the behavior component so we're talking about the mood component so that chronic irritability right so I think of Squidward and angry cat when I think about chronic irritability um so what does that look like so not specific outbursts right so Outburst kind of you have a trigger and then it comes up and then over time eventually comes down for our kids that coming down takes a long time right I saw emotion regulation emotion disregulation and that is one of the deficits or challenges that our kids tend to have um but General grouchiness in this case this is different this is about the mood how what's their you know I ask like I kind of create a pie chart and ask like what percentage of the pie throughout the day would you say your child is irritable angry or grouchy right so these are some of the words that we hear um and sometimes from the kiddos right crumpy grouchy crabby I had a kid who's nickname was Krabby Patty um cranky moody um so these are some of the descriptors that we tend to hear about that mood component piece so you know with parents I will tell you that at least 50% of the time when we do these assessments clinical assessment we hear I feel like I'm walking on eggshells I also think of like Double Dutch and like having to figure out a way to get in there somehow um because they feel like they have to approach them in the right way otherwise they're going to have this big blowout and of course we're trying it's so aversive to the family and very disruptive to let's say the morning routine or we're trying to get out to work we're trying to get you in the car um so it it's this sense of constantly being sort of VI Vigilant by the parents to avoid these uh this chronic uh mood and then what happens is that then the parents um and caregivers in general tend to make accommodations right um in terms of trying to avoid uh children uh being in the state because it is so disruptive and they do have to get to work and things need to happen the child has to

get to school right um so essentially what happens is they tend to miss out on life and it obviously leads to a decreased quality of life you know I've heard parents having to drive in two different cars just to avoid this or missing out on family functions right because the child um tends to have an outburst uh let's say when they're around their cousins or when they're out in particular places or in the summer not being able to go to the pool because the child tended to have a lot of fights there so thinking about that you know it's very sad to hear how people are missing out on just general activities that are important for children to thrive and grow and develop socially intellectually and emotionally right so why is it important to study irritability so you know so far we spend some time highlighting and defining yourability but why is it important to study it and obviously we do that here and that's particularly a majority of my work um so you know like I said already it's one of the most the main reasons why children are referred to psychiatric care um you know there's a couple many studies on this and particularly some longitudinal studies I chose to use Copeland edols 2014 to talk about irly leads to adult impairment um as well as you know sort of leads to anxiety and depressive disorders as adults academic problems um being impoverished as well um you know some of the things that not listed here but they talk a little bit about involvement obviously with the justice system as well as low educational attainment and ultimately as well solici side so thinking about those pieces and you know what's really critical particularly as we move on to talk a little bit more about disruptive mood disregulation disorder is that is highly unlikely for you know a lot of kids who tend to have disruptive mood disregulation disorder might have other disorders um so it's difficult to disentangle sort of how all of these um psychological symptoms sort of play together in a way to lead to these um negative outcomes so essentially again and this is why it is important to identify the symptoms that would then fall within the rubric of this um disruptive mood disregulation disorder that again was created was developed or established in 2013 in the diagnostico manual and I just want to be clear that in terms of the dmdd diagnosis it's it it's reported to have a prevalence of about 3% in the population so um let's walk you through what that looks like so there's a better understanding for all of us about you know what are the actual symptoms of a child who may have this diagnosis so let's start with the temper Outburst right that behavioral component we talked about so what does that look like so severe so remember we made the charge and I asked you what do severe look like so severe recurrent Outburst um so it could be verbal rages or physical aggression towards people or property um out of proportion right it's more than it needs to be sort of again that four-year-old compared to the 12 or 13y old um it's out of proportion let's say for the situation um an inconsistent with developmental level right thinking about um what what's appropriate for a 12 13y old you know and what's appropriate for a foury old so what might be a appr is not so much for a 10 13 year old and has to happen at least three or more times a week so that's a temper out criteria um remember that crabby patty uh Squidward angry cat right that mood component so when they have the pie chart the majority of that pie chart in terms of what your week looks like in terms of your child's mood um irritable or angry most of the day so I say at least 51% of the time so most of that pie is taken up by this feeling irritability in terms of impairment um it has to be present in at least two out of three domains so we categorize the domains as homeschool and peers um severe in at least one of them so um and at least mild in another so it has to reach a clinical level it has to be severe at least in one and present in at least another um present for at least 12 months so how long has this been going on for right there sometimes there events that happen that can lead children to have very strong reactions um and those reactions can look like this but you have to be very cautious in terms of you know are there any precipitant when did this start how long has it been going for have there been any breaks sort of what are you know sort of what's the trajectory of the symptomatology and the development of the disorder and then you know you want to think about development right whether you know we're talking if we're talking about a preschooler or foury old 5-year-old um you know some behaviors might be appropriate might maybe high for a typically developing kid but might not be reaching those clinical levels and then once you reach age 10 then you're talking about things like puberty and there's other factors right and other social demands that come into play so we want to think about this diagnosis where these symptoms have been present prior to H 10 but um but not before H6 and then of course we

want to be mindful about um this not being something like bipolar disorder so we want to sort of exclude for um Mania hypomania so I highlighted that there's two main core DMD criteria and that is that irritable mood 50% of the time another piece of that it has to be noticeable by others not just parents so you're sort of getting reports from peers or from peers parents or schools right they're not being invited to places because you can tell he's he a grumpy pant or she's a grumpy pants um temper outb as well need to be present like we talked about so I do want to highlight one piece so I just spent most of my time talking about disruptive mood disregulation disorder and like I said the treatment I'm going to discuss is something that was developed for the type of irritability present in disruptive mood culation disorder however irritability is present in multiple diagnoses I also mentioned that it is rare for um you know disruptive M culation disorder at times to not have other comorbidities or other disorders or symptoms of disorders that are present so what's interesting about irritability is that it it's highly comorbid and it's present in multiple diagnosis in fact irrit or anger appears as a symptom in about 20 conditions in the DSM including disorders characterized by aggression um and irritability is a multifaceted um dimensional um construct or symptom so we have to be thoughtful that so it is present in uh bipolar disorder major depressive disorder ADHD generalized anxiety disorder separation anxiety social anxiety panic disorder PTSD oppositional Define disorder conduct disorder and Otis spectrum disorder and like I said it's potentially present in more and it shows up but I just wanted to highlight a few the ones in blue that is one of the criteria in fact a form of anger or irritability is a criteria to meet diagnosis for these disorders so again I want to highlight that it is very important to have your child be assessed if you think your child does have irritability at a level that is impairing um or clinical um and it is important for them to be assessed in part because it's also important for them um to identify um what is driving it right what is driving this irritability because knowing what drives the irritability is also going to be helpful in terms of knowing how to treat it um so for example if the irritability is being driven by anxiety Then we need to treat the anxiety as opposed to right if we're talking about trauma um related irritability then there's you know there's some treatments and there's evidence-based practices and um empirically supported treatments for the treatment of PTSD and Trauma related um disorders so you want to be thoughtful about um sort of making sure the first step which is to talk to your pediatrician or your healthcare provider to assess uh whether the irritability is at a clinical level and then you know seeking a specialist in some way who is able to use you know DSM as well as tools to identify and doing a thorough evaluation to assess where the AG is come coming from to then develop a really good um effective treatment plan for your child I do want to highlight that irritability at a high clinical level or high level is uh present in about 2 to 5% of children so again I just want to make sure it's clear how often this occurs and how often we see it when we do um long-term studies so I want to shift a little bit and talk about the other part which I'm sure a lot of you were interested in today and what you wanted to hear about so I'm going to talk a little bit about what's out there in terms of treatments and interventions before I jump into the treatment that we developed so I'm going to just go through some of elements um and sort of features or facets in some theory about what's out there and how it works so one um particular piece of element a piece uh about treating a readability with children right it's about teaching them coping skills so these are some examples and again not everything on that anger management um kind of snippet is relevant but I just took it because it was available so I just want to highlight that um essentially teaching anger management emotion regulation problem solving social skills training so these are some examples of different elements of helpful or useful treatments for IND for kids for individual children um so psycho education on anger right um anger is adaptive and necessary um being angry is important right being and somebody said perceived Injustice when you see an injustice you want to write the Injustice and in order to write that Injustice it is that negative feeling of anger right negative or positive that might motivate that behavior in terms of writing that ingested it is the kid coming home after being bullied or being in some way um you know said something that wasn't fair if they saw

their friend being treated in a way that wasn't fair and coming to you and saying I was really angry about this and then that's when you do something so I just want to make sure that it's clear that anger and irritability are adaptive it's about the levels of of presentation and how the child is expressing that anger and that's what's being taught in a lot of these treatments right identifying those triggers you just gave me a ton of triggers uh very thorough and Nuance triggers at that so that's one of the pieces also where in your body do you feel it so they have more control right the lack of control was something that someone listed um teaching specific skills um how to cool off taking time out deep breathing you know with a lot of the kids that I see they've gone through treatment before these are things that they've T they've been taught and the parents emphasize um another piece is how to express yourself right because a lot of it is sort of a miscommunication piece sometimes not knowing how to express their anger in a way that's adaptive and helpful so being overly aggressive um or passive aggressive but learning how to be assertive how to use eye statements um you know a lot of the elements that I'm describing right now are similar to um the treatments that are out there like cognitive behavioral therapy or dialectical behavior therapy for children um that have been established for um irritability not for iril itself or for disruptive behaviors to be clear so let's talk a little bit about some foundational pieces as we move forward which will also be relevant for the study that we've developed so what are some foundational pieces um of theories um that are effective for parents so we're going to move on to parents so instrumental learning is the process through which organisms learn to perform Behavior to obtain a reward or avoid punishment so it's a way for them to learn behaviors um a stimulus is added or subtracted so um to reinforce means to strengthen or increase the likelihood of the behavior or to punish which really in this case doesn't mean punishment in the way we sometimes use punishment but more it's about decreasing the likelihood of the behavior um and research has suggested that using positive reinforcement is the most effective way to to get Behavior change so for example positive praise would be something like positive reinforcement right you're adding something praise um and then you're trying to reinforce good behavior like great job keeping your arms and legs to yourself um great job using a lower toner voice good job getting through that right so those are all forms of positive reinforcement so you know when you go into sort of instrumental learning as a form of behavior change behavior management what are the triggers again comes up right because you want to know what is the child trying to communicate with the behavior sometimes we ask what is the function and the dysfunction what are they trying to communicate get right what's motivating the behavior what's maintaining it and that's where that reward piece like what's reinforcing strengthening the behavior um and what's punishing decreasing inhibiting the behavior from being presented um for those of you who have gone through treatment before I'm talking a little bit about antic right what happened right before that might have led to the behavior or preceded the behavior the behavior itself right what are they trying to say what are they communicating with the behavior and what are the consequences and not in the sense that we use consequence sometimes as parents but more the responses to the behavior um Action Reaction kind of thing right so ABCs I also want to talk another form of another theory foundational theory of some parent management trainings um which is this course cycle so here we have a parent making a demand or giving a child a directive like brush your teeth the child then refuses let's say they say no um the parent then threatens brush your teeth or else you're not going to watch your iPad today um and then the child pushes or hits the parent and then let's say the parent of course has to get to work and doesn't want to deal with it because it's a lot um so they just kind of give up so in this case the child then learns that an outburst or refusing to do things will work for them um let's flip to the other side right sometimes let's say the parent same thing parent makes a demand the child says no the parent says you're going to lose your iPad if you don't do it and then the child then goes and brushes their teeth so then the parent learns that threatening or coercing the child um works so then of course what happens so the behavior becomes reinforced so again it's this bir directional relationship between parent and child in which Co cotion is being used and that's being re enforced one of the challenges with this and it is difficult to break particularly you know children who tend to have um irritability who tend to be non- compliant or have negative responses tend to elicit greater negative responses from their caregivers as would be expected right it is frustrating to have a child yelling or Screaming or saying no when you ask them to do something so you yourself can get angry and then respond in that way so what happens is the behavior is reinforced in both sides right so both parent and child are being reinforced for their behavior and therefore they're more like to engage in that behavior in the future obviously escalation matters

because then it increases how much more you threaten how much more they threaten how much they for and of course it leads to the sense of helplessness which a lot of the parents when I see them tend to feel that helplessness about how um this course of cycle kind of maintains itself so in line with that a lot of the treatments also try to break this cycle and that's a lot of what they're trying to do so in doing so um they use these principles of instrumental learning so contingencies for rewards and Punishment right that's what instrumental learning is um sort of phrase um what kinds of things are you providing for your child to reward them or punish them for their behavior um and again we don't condone corporal punishment just to be clear when we talk about punishments we means uh things that you do in order to decrease the likely or inhibit s of the behavior so staying consistent labeled praise special time um these are some of the things obviously setting limits and then different behavior management training have timeout break time call of time they're all term differently because they all have a different goal but they might look similar so these are some of the pieces that are used in some of the behavior management training and of course parent stress and emotion regulation we talked about the course of cycle having a child who has elevated levels of irritability is um sort is very difficult and can be frustrating at times I would say to say the least so therefore you attending to your own emotion and then the child also learns um through you so being able to manage your emotions and then what do you communicate about anger and how do you express your anger in the system one last piece about some helpful aspect obviously the parent child interaction is critical um so you know talking about increasing positive interactions decreasing negative interactions and then that emotional bank account um so five positive interactions for every negative so adding money to the bank so that when you have to make a withdrawal whether it is a demand or give a child directive or reprend the child you have enough in the bank where the child is more willing to comply um and then making sure you know you're communicating effectively with your child and being clear and and making sure that expectations are set in a way that the child um that you become predictable in that way so those are a little bit of my quick brief overview of aspects and different fundamental pieces of U different types of treatment whether individual or parent Management training now I want to move on to our studies um and what we've developed so like I said I'm a clinical psychologist here at the neuroscience and Ne Therapeutics unit um what we do here is we develop treatments for children with emotional problems by studying the brain um and we try to use non-pharmacological behaviorally based treatments to do that the way we study children is we look at computer tasks like attention frustration and memory and their reaction time uh we do a lot of brain Imaging so we put children in the scanner and look at the brain mechanisms related to irritability and anger particularly we look at the prefrontal cortex and the amydala which are areas implicated in Emotion regulation as well areas about attention and frustration and reward processing as well um we also engage in digital based phenotyping so we use smartphones and warbl to collect data like heart rate variability as well as assessing what people are doing in real time in their real world right this applies to your life in the real time at home so we want to know what's happening in the home whether the treatments are effective and also what's happening with the children in terms of how they're feel during that time so this is a little bit complicated um but I'm going to go through it uh so this is one of our since I talked about theories for other treatments I want to highlight theories for our treatment um so this is a translation mod of irritability developed by our fearless leader Dr uh Melissa bman there all the way on the far right um and uh Dr kuransky has also um written about this uh in terms of our treatment so I just want to kind of highlight uh our basis for our exposure based treatment um just to give you a theory um in case you're interested so the way we conceptualize irritability is that they're multiple facets and there's essentially challenges in areas of reward processing and threat processing so what do I mean by that so reward processing meaning um you know sort of children have certain expectations about getting a reward whether it is oh you know if you complete your homework uh we'll go out for ice cream right and then they have strong reputation and then if you don't do that they're going to have a strong reaction if they don't receive set reward right um and then with threat processing children um with irritability tend to see neutral faces as more um sort of negative um and they also tend to focus on faces that they perceive to be threatening um so we're looking at particularly talk a little bit about then deficits in instrumental learning like the content right so the content of what is within that instrumental learning so the contingencies for the

behavior so what the parent provides whether it's praise um what kinds of rewards they give things like that um and then there's also in terms of their process they have deficits in instrumental learning so when to expect rewards and how to adjust their behavior when those contingency change right if something changes if you no longer are giving a treat let's say for homework completion they're going to have a strong reaction to that um so this is sort of my way of trying to explain this model and what we think is that they have a lower threshold right which then leads to um these challenges for these children and then the response is increase mortar activity and aggression right what is that well that's that behavioral piece that's that temporal burst and then anger increase anger and frustration right um which is that mood component um so what we're trying to do is we devop treatment that tries to Target um these areas that we think that have um are challenging for our kids with dmdd that have or that have that level of irritability so what we uh proposed was to expose children to threat and frustration while tolerating their anger um to normalize those areas that processing of reward that processing of threat um so that they decrease their anger and frustration so why exposure so we think we know that exposure Works in anxiety and irritability are very similar in terms of their responses so they both have to do with responses to threat right so when they have a perceive threat so think of fight flight or freeze so instead of flighting right it seems like children with irritability tend to go towards approach or fight and then similar to anxiety right they're both kind of shortterm they both start somewhere and then higher rouso state meaning it evokes energy right it evokes energy or in the system so something happens the child becomes irritable or anger it comes up and then it goes down so the same thing right if a child is anxious about an upcoming exam let's say or presentation um and then the presentation happens they got to go up right and then the anxiety comes back down so we think that they're both very similar and that's why we think exposure so being able to expose the children to the anger inducing stimuli while tolerating the anger without engaging in these responses will help them um and then of course we want to also tackle the instrumental learning component and we do that through parent Management training um so addressing sort of how we praise how we reward um sort of the reward contingencies for the children in terms of their behavior and then sort of what to set expectations in a way that are more predictable for children so let's go into what is exposure therapy I'm sure stor of you are familiar particularly mental health providers here um so it's technique that involves changing one's Behavior to um treat fear and anxiety and involves areas of the brain related to attention and emotion regulation like the omeg blood and the prefrontal cortex so patients are repeatedly exposed to a feared object or stimuli and we create a fear hierarchy so a list of objects that tend to induce fear in the child or anxiety so what we do is we create what's called a Suds a subjective units of the stress and then we identify levels at which the child um would feel anxiety at different levels so let's say seeing a picture of a spider might induce less anxiety as opposed to seeing a spider through a glass as opposed to touching a spider and of course this would probably also be an exposure for most of us um would induce a lot more fear so the idea is that we move up then the child is able to see a spider and sort of not engage in the avoidance behavior that they used to so in the past let's say a child who has this fear a fear of bugs might not go out let's say because they're afraid they might see a SP but being able to help them approach the spider over time will de will mute the response of anxiety and ultimately allow them to thrive and continue to live their life despite them being spiders out there so we think that trying to translate exposure for anxiety to irritability would work for um addressing those pieces in that translational model so instead of hierarchy of fear inducing stimuli to anxiety say the spider through the glass we would do a hierarchy of anger inducing stimuli for reability and I have to say for the person who said folding laundry very good job so here it is yeah folding laundry um you know it's it's seven to five seven but five to seven business days to fold it um it takes it's frustrating to most uh and some of our kids definitely throw tempor outp bur having to do that so that would be uh IR irritability inducing stimuli um instead of changing the avoid strategy right in anxiety we would change the approach strategy in irritability like aggressive or temper Outburst so what are some common

components I do want to be clear that this is not intended for those with uh a trauma history and that there are obviously um treatments out there for um individuals who do have irritability as a result let's say of trauma or some form of trauma related disorder such as PTSD so this is more for children who have irritability as that sort of similar to the one that I described in dmdd so we do motivational interview we took that from some of the substance use literature um to try to get the child on board right get them bought in It's usually the parent who's seeking treatment not the child the child's kind of like so we want to make sure that they're here because they want to be here and we identify Target treatment targets and acknowledging again that anger is helpful and sort of what's causing the problems and we try to tackle the problems of anger not anger in it of itself per se um we talk about the same things we talked about earlier in terms of where do you figure anger what does your anger look like and then the critical piece is this exposure component right um the hierarchy in session exposure to try to inhibit those maladaptive approach responses everything that you listed in terms of those temper outbursts um as well as inhibitory control teaching our children to inhibit um their response to try to aggress or yell or scream um and then we have parent sessions that are focused on learning theory like I talked about before um so rewarding positive being consistent being predictable in that way pray active ignore setting limits and providing effective commands so um this was covered in a Wall Street Journal article um how to and there was a description about this particular kid with the folding laundry so I'll walk you through that so essentially what we did we developed the anger hierarchy for this child and we started with sort of just looking at the laundry and then ultimately starting to sort folding the laundry and we extended this to other children they say brushing their teeth uh having to do hard homework or stop playing video games which is really challenging so how does this look like in session um essentially we prepare the chat for the exposure child predicts from 1 to 10 how angry they're going to get we ask them for a baseline rating and then we engage in the exposure whatever it is whether is we have them brush their teeth sometimes we'll play a two-on-one basketball game so they get used to losing or we'll rig the game um so these are some of the things we do in order to expose the child to those anger inducing stimuli and it's very specific for the child after we created this list of anger inducing um events or situations that are specific to that child this is an example from an actual child so as you can see anger goes up and comes down right this is what I was telling you about phasic and acute in this way and eventually over time those Peaks become lower and lower and the child gets used to either this the event which then translates to other things whether it's ches at home or having to do uh laundry or whatever else it is so I want to give a shout out to the wonderful clinical team and all their hard work to help us identify whether this works and providing the treatment um so let's look a little bit about what this looks like so I want to make sure we're clear about who the sample is uh right now in terms of this particular sample I'm going to be talking about we completed it with 40 youth predominantly children with dmdd um mostly males um about 11. 23 years old and of course um we are currently working in terms of trying to change our diversity data in terms of um getting um more individuals from uh diverse cultures but currently it's predominantly white in terms of the sample so does it work um we had a multiple Baseline design because we wanted to provide the treatment to everyone since it is a new treatment um we had kids uh do have a baseline period in which they we were just following them without any treatment and as you can see here according to clinician rated irab and the clinicians didn't know when the child started the treatment cuz we had children start treatment at 2 4 or 6 weeks um there were no significant changes however during the treatment period when the exposures and parent Management training was provided the child did uh decrease their irritability um significantly and what we see here is that those changes were maintained so the children did stay better over time and didn't go back to pre-baseline levels so what can we say about the treatment right firstly we showed that exposure could work for irritability so we identified a procedure um that works for that we also showed that children do tend to change their approach of behavior so temper out first decrease as well as their irritable mood some limitations are that we don't have a comparison group so everybody knew they were getting the treatment um so that kind of creates a challenge because we don't know if it's just getting treatment that makes them better or is it something unique about what we hypothesize particularly the exposures that caused this change or LED to this change and then families knew they were getting to treatment so again they have these beliefs or expectations and we

don't know how it works so here's some future um ideas that we have about how um to test how it works and we're currently looking at how areas of the brain are involved in Emotion regulation and attention like that prefrontal cortex amydala um areas that we talked about we're also looking at signs of change during the exposure so now children wear a watch that um assesses it's not really a watch but um assesses their heart rate and heart rate ability and like I said before we have children go out in the real world um with uh phones um and the parents to identify what irritability outburst and those behaviors look like in real time as well as set thing um parents use of the interventions um in terms of their real day-to-day life so I do want to provide you with some resources I'll give you some time to QR code these um these are some possible resources um for you to look at um if you have more questions or it sounds like H maybe I do know a kid like this maybe this is my child um these are places that you can go to possibly to learn more um and well I listed a couple of books that are also uh resources particular the middle one if you have been through um what's called parent child interaction training this is the book that they have a companion book for parents as well as some other books that are available out there for children who have um these types of disruptive um behaviors that might be similar and also um they're being added to the chat so if you just want to click on the link in the chat um you can just click on that and hopefully they stay open for you and you're able to um get that well I want to say thank you to all our patients and families primarily because without their devoted time and um alteristic Behavior we would not be able to do any of this work and present it to you so we're very grateful to them as well as all the individuals here uh you know particular Dr Brookman who's the leader of our lab Danny Pine L Collins Jamal Lisa um all these individuals Cen thank you so much she's there in the background doing the work um she's the one sending you this so thank you as well as all the other staff that we have and I couldn't put everyone's name here I wish I could but I want to say thank you to everyone um for all all the work that we um can do so and I want to say thank you to you for coming today I really appreciate you coming and listening to us um we are recruiting for that study that I just talked about um I do want to highlight and emphasize that we are looking for individuals who are within a 50 m radius of NIH um particularly we are in the Bethesda campus so 50 m radius from the Bethesda campus here that's where I'm talking to you from today um and of course uh just to be clear there's certain forms that would be exclusionary so just click on that and you can get started with our process if you're interested oh thank you I don't see Dr Hermon I'll go ahead and just type those into the chat for you great thank you oh that's a great question so essentially one of the key critical pieces and differences is going to be that mood component for sure um in terms of so one of the questions what a difference between oppositional I think it's Oppositional Defiant is that what they're asking for disorder in dmdd um do you think that's the question yes correct okay um so yeah so essentially one of the key differences is going to be that mood component with dmdd particularly that 51% of the time the child tends to be irritable there is a large debate around um what would ultimately um you know whether there's a difference in terms of the gmdd diagnosis and the oldd diagnosis but um

you know when you think about the criteria you think about these two components particularly the two domains that I talked about I would say that mood piece is going to be critical there are serious uh large overlaps uh between the two in terms of OD um and obviously with Oppositional Defiant Disorder um if a child does have dmdd then they do not get an opposition Define disorder diagnosis because dmdd subsume OBD according to the DSM both tempers can look very similar and of course there's obviously some other pieces about the diagnosis so dmdd is exclusiv reserved for um children or youth um so one of the critical pieces of the diagnosis is that it has to be present um prior um to age 10 and then um after age six so I would say dmdd uh would not be a diagnosis given in an adult per se um so I think assessing how long the irritability has been for remember it has to be at least a year um so I would venture to try to identify the root of the irritability and where these anger management issues are coming from and whether there's other components there right in terms of and I understand that here it says they don't be criteria for anxiety bipolar depression so and I think that's what's complicated sometimes about DSM sort of putting people in those buckets and particularly the demarcation that DSM provides with the you know criteria sometimes doesn't fit quite neatly in the patients that we end up seeing so um finding sort of what looks like a good treatment for um I mean a good diagnosis for this person why did I say treatment because the diagnosis will inform uh the treatment right what treatment you provide and sort of what your treatment clim looks like um so that would be my best way of answering that great question um how do ADHD and dmdd intersect so there is a huge overlap and I will be transparent that I would say at least 80% of our children do have ADHD um so I would say that in that sense that there is a they they're they can be comorbid um and then you know with ADHD there's a lot of other um pieces in terms of the in attention the hyperactivity um as well as um sort of those challenges that can be present that may not necessarily be present in dmdd so I think it's really identifying triggers for the irritability so what are the triggers I think that's usually where I start and then that can help me sort of have a better diagnostic picture so I take a really good so walk me through your week and when was the last time your child so I would take I would try to go through at least certain outbursts like is it a specific time is it doing homework is it at school um you know is it what are the demands in the situation particularly when it comes to children with ADHD you know are they being asked to sit still pay attention what are the kind of pieces that are are the factors that are at play right now that would lead this person or this child to be irritable or Express anger or have a tempor out burst in this way compared to children with the MDD um so I would say that those are some of the components also that mood component is critical right because dmdd is part of the mood disorders so how often is the child irritable and what is their Baseline mood I usually start there and what would you say is you know again that pie what percent of the time did they spent um being angry or irritable versus other um and then of course triggers and what that looks like so yeah I it's interesting because I didn't put intermittent explosive disorder in the like I said there's about 20 DSM disorders that could have it so intermittent explosive disorder I when I think about it differently I think about yes The Temper out is there um I think about reactive aggression versus proactive aggression sometimes right so one piece about dmdd is that most um our kids who would get diagnosed with dmdd they have reactive aggression so usually it's in Rel to um some form of of incident that happened remember something happen and then they get angry and then they express it for the most part um so I would say in general I tend to think about that as a differentiating component um as well as you know sort of these other criteria as it relates to dmdd like what would the trigger how long has it been what starts it and then um are they being reactive or are they proactively aggressing somebody you know is there no particular incident or something that happened was there not um that led to that um as well as the other

pieces related to what's in the DSM themselves about those disorders oh look at the time so thank you everyone for coming um I can't see you but um thank you again for being here I'm very grateful to have been had the opportunity to share this with you I hope you found it helpful um and yeah please stay tuned for um the next one of these which will be in a couple of months or so thank you