Question 1

How do you manage the risk of aggressive behavior and potential property damage, for example, during the exposures?

Melissa Brotman · Accepted Answer

Therapists must conduct a very extensive clinical interview before deciding if the treatment is appropriate for a child and their family. We do not engage in exposures with children if we do not think the child or others around them would be safe. We ask children and parents to describe how the child expresses anger and temper outbursts. The safety of the child is always our top priority. Again, we work our way up the anger hierarchy, starting with less frustrating situations first.  We are constantly monitoring the child’s readiness for exposures.  Indirectly, we also teach the children to monitor their own readiness for exposures. Before we start any exposure, we ask the child to predict their anger level for the specific exposure.  If the child were to predict a much higher level of anger than the clinician would have anticipated, the clinician may choose to modify the exposure after debriefing with the child.

Question 2

Are the exposures that you do similar to exposure therapy for anxiety disorders?

Melissa Brotman · Accepted Answer

The process of identifying situations and events for anxiety and anger exposures are similar in that in both cases therapists generate a hierarchy. However, the content of the two treatments differs significantly. Events that are associated with anxiety, such as being separated from a caregiver or a big storm, are different from situations that lead to anger, like losing a game or perceiving something as unfair.

Question 3

What mechanisms do you think are happening in the in vivo exposures that help children learn to tolerate frustration?

Melissa Brotman · Accepted Answer

A key piece for children is learning that they can sit with and tolerate their anger without having a temper outburst and their anger will eventually decrease. Although feeling the anger and frustration can be unpleasant, developing a sense of control over the emotions is empowering.

Question 4

How keen are parents to have their children exposed to frustrating experiences? Are parenting strategies included as part of your treatment? This seems like it would be a difficult approach for parents who want to avoid their children's tantrums and outbursts?

Melissa Brotman · Accepted Answer

Both parents and children provide consent and assent, respectively, prior to starting the treatment. The treatment is as much about exposing the child to frustrating experiences as teaching the parents behavior management strategies and skills to manage the child’s outbursts and irritability. The parents are typically eager to have their children learn skills to deal with their anger and irritability. Parents are invited to be involved in the initial discussions around developing an anger hierarchy with the child. In working with the children, the therapist asks the child what they want to work on and if they see their anger and irritability as causing problems for them. Most of the time, children say they wish they could control their anger more and they have lost friends, privileges, or other things because their anger got in the way. As clinicians, we see ourselves as facilitating the child’s wishes and helping them gain more control over their emotions. Children typically see this as empowering and are eager to learn skills to decrease their tantrums and outbursts. As part of the treatment, we also work directly with the parents and provide parent coaching sessions in which we share techniques geared towards teaching parents new ways of responding to their child’s anger. A foundational aspect of this is helping parents to have a better understanding of what is motivating their child’s temper outbursts and sharpening their skills in identifying how their reactions to their child’s behavior may be inadvertently reinforcing these outbursts. We are also focused on helping parents learn new ways of increasing positive interactions with their child.

Question 5

What does your exposure-based CBT protocol for irritability in children involve? Do you teach the self-regulation skills that you might want the kids to use in the exposures?

Melissa Brotman · Accepted Answer

Our exposure-based CBT protocol is based on the idea that exposing youth to their anger-inducing triggers in a therapy context will, over time, lead them to be less reactive to those triggers. They will also learn to inhibit their tendency to express frustration in unhelpful ways by learning to tolerate their anger. Our exposure-based CBT protocol starts with the child and clinician generating a “hierarchy” of anger-inducing events and triggers. The therapist will ask the child to talk about events and situations that make them “a little angry” at a level 1 or 2 (out of 10); then, the clinician will elicit medium level anger exposures at a level 4 or 5; and then things that make the child very angry at a level 8 or 9. After talking about the different levels, the clinician will ask the child to draw and talk about how they know they are angry and where the child feels the anger in their body. After several sessions and discussions, the child will practice a “low level” exposure that makes the child a little angry. Sometimes this will involve simply talking about an event that made the child angry. Once the child has a mastery experience with a low-level trigger, the therapist will slowly move up the anger hierarchy over the course of several weeks. Although the therapist may teach the child relaxation or breathing techniques, we do not directly teach self-regulation skills. Instead, we encourage the child to notice the feelings in their body, tolerate the physical feelings associated, talk with the child about “ok ways” and “not ok” ways to express anger, and learn that, over time, the feelings go down.

Question 6

What are common triggers for kids that struggle with temper outbursts and irritability?

Melissa Brotman · Accepted Answer

Some of the most common triggers in youth with temper outbursts and irritability are having to transition from one activity to another — that is, having to transition from a preferred activity (for example, playing video games) to a less preferred activity (such as homework), or having to transition from an enjoyable activity to a mundane activity of daily living (for example, brushing teeth). Other common triggers we see are children asking for a specific object or reward (such as a toy, treat, screentime) and being told “no.” Children being asked to do household chores (such as emptying a dishwasher or setting the table) and feeling like something is unfair are associated with temper outbursts in some youth with DMDD.

Question 7

Is it temperament or other factors such as learning and family environment that causes irritability and frequent anger outbursts in children?

Melissa Brotman · Accepted Answer

We have found that many factors influence a child’s development of mental health problems related to anger and irritability, including both the family environment and biological factors. We have also learned that both psychological treatments, such as Cognitive Behavioral Therapy (CBT) and Parent Management Training (PMT) and certain psychiatric medications can help children with severe and impairing irritability.

Question 8

Can pediatric irritability sometimes be mistaken by parents or carers for typical childhood behaviors?

Melissa Brotman · Accepted Answer

Irritability, similar to other emotions and feelings, can be associated with psychiatric disorders, but it is also present in children and adolescents (and adults!) without a clinical diagnosis. In fact, irritability is developmentally normative. That means there are certain times in development when irritability tends to be more common. We know from research that irritability tends to peak during preschool years and also during adolescence. To determine if the irritability is clinically worrisome, parents should consult mental health providers. A therapist, psychologist, or psychiatrist can determine if the child’s irritability is causing functional impairment. The practitioner may ask about the frequency of the anger and irritability (how often the child experiences anger and irritability), the duration of the anger (how long the child remains angry), and the threshold of the anger (how easily does the child get angry, annoyed or irritable). To assess functional impairment, the clinician may ask about the child’s family relationships, peer relationships, and ability to get along in school and with teachers.

Question 9

What are the symptoms of pediatric irritability in a child and is it a sign of a DSM disorder?

Melissa Brotman · Accepted Answer

Irritability has been conceptualized as a low threshold for experiencing anger or frustration. There are two manifestations of irritability: phasic irritability and tonic irritability. Phasic irritability is a behavior a parent, teacher or friend would be able to observe. Phasic irritability is defined as behavioral or temper outbursts of intense anger. A child yelling, screaming, slamming a door, or throwing a toy or controller would be examples of phasic irritability. Tonic irritability is defined as a persistently angry, grumpy or grouchy mood. We often hear parents say they are “walking on eggshells” around their irritable child to avoid an outburst. The Diagnostic and Statistical Manual Of Mental Disorders has used the classification of disruptive mood dysregulation disorder (DMDD) as a mood disorder that may be present in youth whose cardinal symptom is clinically impairing severe chronic irritability. DMDD is a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts. That is, the child experiences both tonic and phasic irritability. Youth who have DMDD experience significant problems at home, at school, and often with peers. The problems and difficulties that stem from this level of chronic severe irritability must be severely impairing in at least one of these areas and must also be present in another area. It is important to be aware that irritability is also often present in other diagnoses in children and adolescents, including generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, oppositional defiant disorder, attention-deficit/ hyperactivity disorder, and autism spectrum disorder. Of note, there are several life and environmental stressors that can increase or decrease a youth’s level of irritability and it’s always important to consider the context, any recent changes or transitions, and the developmental level or age of the child when considering whether the youth’s irritability would warrant a clinical diagnosis.

Exposure Therapy for Pediatric Irritability