Psychological Treatments for Youth With Severe Irritability.
| Status: | Recruiting |
|---|---|
| Conditions: | Cognitive Studies, Psychiatric |
| Therapuetic Areas: | Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 8 - 18 |
| Updated: | 2/10/2019 |
| Start Date: | August 22, 2015 |
| End Date: | December 30, 2022 |
| Contact: | Melissa A Brotman, Ph.D. |
| Email: | brotmanm@mail.nih.gov |
| Phone: | (301) 435-6645 |
Background:
When children have severe irritability and temper outbursts, they can be so cranky or angry
that it leads to problems at home, in school, and with friends. This is called Disruptive
Mood Dysregulation Disorder (DMDD) and there have been no psychological treatments developed
specifically for children with this problem. Researchers think two forms of therapy,
Cognitive Behavioral Therapy (CBT) and Interpretation Bias Training (IBT), might help
children with DMDD.
Objective:
To test two whether IBT and CBT can decrease severe irritability in children and youth.
Eligibility:
Children 8-17 years old with DMDD. Their symptoms must have started before age 10.
Design:
Participants will be screened with a review of their symptoms. Parents and participants will
answer questions.
Participants can do only one or both of these treatments if they wish. Those who wish to do
both will start with IBT.
Participants who do CBT will have 12-16 weekly meetings of research talk therapy. A parent
will participate in part of the sessions.
Participants will talk about what makes them irritable and how it affects them. They may be
put in situations that might make them annoyed or irritable.
Participants will rate how intense their irritability is. Parents and participants will
complete rating scales, questionnaires, and interviews.
Participants will do practice activities at home.
Participants doing IBT will have up to 14 sessions over 10 weeks.
Participants will view 15 faces, one at a time, on a computer. They will choose if the face
looks happy or angry on a computer. Sometimes the computer gives feedback. Participants will
complete some sessions at the NIH and some at home.
Participants and parents answer questions about their progress.
When children have severe irritability and temper outbursts, they can be so cranky or angry
that it leads to problems at home, in school, and with friends. This is called Disruptive
Mood Dysregulation Disorder (DMDD) and there have been no psychological treatments developed
specifically for children with this problem. Researchers think two forms of therapy,
Cognitive Behavioral Therapy (CBT) and Interpretation Bias Training (IBT), might help
children with DMDD.
Objective:
To test two whether IBT and CBT can decrease severe irritability in children and youth.
Eligibility:
Children 8-17 years old with DMDD. Their symptoms must have started before age 10.
Design:
Participants will be screened with a review of their symptoms. Parents and participants will
answer questions.
Participants can do only one or both of these treatments if they wish. Those who wish to do
both will start with IBT.
Participants who do CBT will have 12-16 weekly meetings of research talk therapy. A parent
will participate in part of the sessions.
Participants will talk about what makes them irritable and how it affects them. They may be
put in situations that might make them annoyed or irritable.
Participants will rate how intense their irritability is. Parents and participants will
complete rating scales, questionnaires, and interviews.
Participants will do practice activities at home.
Participants doing IBT will have up to 14 sessions over 10 weeks.
Participants will view 15 faces, one at a time, on a computer. They will choose if the face
looks happy or angry on a computer. Sometimes the computer gives feedback. Participants will
complete some sessions at the NIH and some at home.
Participants and parents answer questions about their progress.
OBJECTIVE:
This purpose of this protocol is to further the development of two potential
non-pharmacologic treatments for youths with chronic, severe and impairing irritability. The
first potential treatment is Interpretation Bias Training (IBT), a computer-based training
designed to shift emotional judgments of ambiguous faces away from angry, and toward happy,
judgments. The first component of this protocol includes a randomized, controlled trial of
active IBT in youth with severe irritability. The second potential treatment is a cognitive
behavioral therapy (CBT) targeting severe irritability. The goal of this protocol is to
conduct a preliminary study using a randomized within-subjects multiple-baseline design to
test the efficacy of a new manualized exposure-based CBT with parenting training in the
treatment of severe irritability.
Objective 1: Assess the efficacy of Interpretation Bias Training (IBT) in youths with severe
irritability, operationalized as those meeting criteria for DSM-5 Disruptive Mood
Dysregulation Disorder (DMDD). To accomplish this objective, we will conduct a randomized,
controlled trial (RCT) of active IBT in 40 youths with DMDD. Subjects will be randomized to
receive four IBT training sessions (active vs. placebo, in a double-blind design) over four
days followed by weekly mood ratings for two weeks. Primary outcome measures in this trial
will assess changes in irritability using the Affective Reactivity Index (ARI:
clinician-rated, parent-rated, and child-rated) and Clinical Global Impressions-Improvement
(CGI-I). After completing the RCT, all participants will be offered four open, active IBT
sessions, delivered on the same schedule as in the RCT and using the same primary outcome
measures.
Objective 2: Test the efficacy of a new manualized CBT for severe, impairing irritability in
youth. To accomplish this objective, we will utilize a within-subjects multiple baseline
design (Onghena & Edgington, 2005; Gliner, Morgan, Harmon, & Harmon, 2000; Morgan & Morgan,
2001). The children will be randomized to their start times. Clinical ratings, as well as
parent- and child- report ratings will be obtained every two weeks (plus or minus two days)
during both the baseline and active periods. This is not an RCT. All children will receive
active CBT following variable (randomized) start times. Consistent with the manual we will
continue to meet with children and their parents utilizing newly manualized exposure-based
CBT procedures, such as eliciting hierarchies of irritability inducing events, exposure
exercises (e.g., in-vivo, role-play, imaginal) and parent training. We will conduct the CBT
on N=40 youth with severe, impairing irritability. Primary outcome measures for CBT will
assess changes in irritability using the ARI (clinician-rated, parent-rated, and child-rated)
and CGI-I.
Secondary Objective 1a and 1b: Assess the effect of IBT on clinical measures of depression,
anxiety, and functional impairment.
Secondary Objective 2: Assess the effect of the CBT for irritability on clinical measures of
depression, anxiety, and functional impairment.
Subjects can participate in one or both of these potential treatments. If they opt to do
both, there will be a four-week wash-out period between treatments.
STUDY POPULATION:
The study is taking place at the National Institutes of Health (NIH). All outpatients, ages
8-17, enrolled in NIMH-DIRP Protocol 02-M-0021, who are in stable treatment in the community
will be invited to participate in this study.
DESIGN:
The first part of the protocol will involve conducting a randomized controlled trial of IBT
in 40 youths who meet criteria for DMDD. The goal of this novel, potential treatment is to
decrease the severity of the child s irritability.
The second part of the protocol will involve conducting a randomized within-subjects
multiple-baseline trial of CBT targeting severe irritability including N=40 youth.
Subjects can elect to participate in the IBT randomized controlled trial only, CBT treatment
or both. If subjects elect to participate in both IBT and CBT, there will be a one-month
wash-out period in between.
OUTCOME MEASURES:
The main outcome measures will assess changes in irritability using the ARI (clinician-rated,
parent-rated, and child-rated, original and revised versions for IBT and CBT, respectively)
and CGI-I. Secondary measures include parent and self-report measures of depression, anxiety,
anger, social status, and aggression, as well as clinician ratings of depression, anxiety,
and impairment. Data for ecological momentary assessments (EMA) will be collected using
secure technology, with procedures approved by the NIMH ISSO; subjects and their caregivers
will be asked a set of questions relating to recent experiences and emotions
This purpose of this protocol is to further the development of two potential
non-pharmacologic treatments for youths with chronic, severe and impairing irritability. The
first potential treatment is Interpretation Bias Training (IBT), a computer-based training
designed to shift emotional judgments of ambiguous faces away from angry, and toward happy,
judgments. The first component of this protocol includes a randomized, controlled trial of
active IBT in youth with severe irritability. The second potential treatment is a cognitive
behavioral therapy (CBT) targeting severe irritability. The goal of this protocol is to
conduct a preliminary study using a randomized within-subjects multiple-baseline design to
test the efficacy of a new manualized exposure-based CBT with parenting training in the
treatment of severe irritability.
Objective 1: Assess the efficacy of Interpretation Bias Training (IBT) in youths with severe
irritability, operationalized as those meeting criteria for DSM-5 Disruptive Mood
Dysregulation Disorder (DMDD). To accomplish this objective, we will conduct a randomized,
controlled trial (RCT) of active IBT in 40 youths with DMDD. Subjects will be randomized to
receive four IBT training sessions (active vs. placebo, in a double-blind design) over four
days followed by weekly mood ratings for two weeks. Primary outcome measures in this trial
will assess changes in irritability using the Affective Reactivity Index (ARI:
clinician-rated, parent-rated, and child-rated) and Clinical Global Impressions-Improvement
(CGI-I). After completing the RCT, all participants will be offered four open, active IBT
sessions, delivered on the same schedule as in the RCT and using the same primary outcome
measures.
Objective 2: Test the efficacy of a new manualized CBT for severe, impairing irritability in
youth. To accomplish this objective, we will utilize a within-subjects multiple baseline
design (Onghena & Edgington, 2005; Gliner, Morgan, Harmon, & Harmon, 2000; Morgan & Morgan,
2001). The children will be randomized to their start times. Clinical ratings, as well as
parent- and child- report ratings will be obtained every two weeks (plus or minus two days)
during both the baseline and active periods. This is not an RCT. All children will receive
active CBT following variable (randomized) start times. Consistent with the manual we will
continue to meet with children and their parents utilizing newly manualized exposure-based
CBT procedures, such as eliciting hierarchies of irritability inducing events, exposure
exercises (e.g., in-vivo, role-play, imaginal) and parent training. We will conduct the CBT
on N=40 youth with severe, impairing irritability. Primary outcome measures for CBT will
assess changes in irritability using the ARI (clinician-rated, parent-rated, and child-rated)
and CGI-I.
Secondary Objective 1a and 1b: Assess the effect of IBT on clinical measures of depression,
anxiety, and functional impairment.
Secondary Objective 2: Assess the effect of the CBT for irritability on clinical measures of
depression, anxiety, and functional impairment.
Subjects can participate in one or both of these potential treatments. If they opt to do
both, there will be a four-week wash-out period between treatments.
STUDY POPULATION:
The study is taking place at the National Institutes of Health (NIH). All outpatients, ages
8-17, enrolled in NIMH-DIRP Protocol 02-M-0021, who are in stable treatment in the community
will be invited to participate in this study.
DESIGN:
The first part of the protocol will involve conducting a randomized controlled trial of IBT
in 40 youths who meet criteria for DMDD. The goal of this novel, potential treatment is to
decrease the severity of the child s irritability.
The second part of the protocol will involve conducting a randomized within-subjects
multiple-baseline trial of CBT targeting severe irritability including N=40 youth.
Subjects can elect to participate in the IBT randomized controlled trial only, CBT treatment
or both. If subjects elect to participate in both IBT and CBT, there will be a one-month
wash-out period in between.
OUTCOME MEASURES:
The main outcome measures will assess changes in irritability using the ARI (clinician-rated,
parent-rated, and child-rated, original and revised versions for IBT and CBT, respectively)
and CGI-I. Secondary measures include parent and self-report measures of depression, anxiety,
anger, social status, and aggression, as well as clinician ratings of depression, anxiety,
and impairment. Data for ecological momentary assessments (EMA) will be collected using
secure technology, with procedures approved by the NIMH ISSO; subjects and their caregivers
will be asked a set of questions relating to recent experiences and emotions
- INCLUSION CRITERIA:
Inclusion criteria for both Interpretation Bias Training and Cognitive Behavioral Therapy
Studies:
1. Age 8-17 years
2. Must be enrolled into NIMH DIRP protocol 02-M-0021, Characterization and
Pathophysiology of Severe Mood and Behavioral Dysregulation in children and youth.
3. Must meet DSM 5 diagnostic criteria for DMDD which are (for CBT, must meet lifetime
history of either DMDD or one of two core DMDD criteria [b or c]):
- Must meet all of the following:
1. Diagnosis must first be made between ages 6-18 years
2. Abnormal mood (specifically, anger and/or irritability), present at least
half of the day most days, and of sufficient severity to be noticeable by
people in the child s environment (e.g. parents, teachers, peers).
3. Compared to his/her peers, the child exhibits markedly increased reactivity
to negative emotional stimuli that is manifest verbally or behaviorally. For
example, the child responds to frustration with extended temper tantrums
(inappropriate for age and/or precipitating event), verbal rages, and/or
aggression toward people or property. Such events occur, on average, at
least three times a week.
- The symptoms in b and c above are currently present and have been present for at
least 12 months without any symptom-free periods exceeding two months.
- The onset of symptoms must be prior to age 10 years.
- The symptoms are severe in at least one setting (e.g. violent outbursts,
assaultiveness at home, school, or with peers). In addition, there are at least
mild symptoms (verbal aggression) in a second setting.
4. Patients must be fluent in English
1. All instruments have not been validated in other languages.
2. Psychotherapy will be designed and conducted in English.
5. On the basis of record review and interviews with child and parent, the research team
agrees that the child s response to his/her current treatment is no more than minimal
(i.e. CGI-S of 3 or more).
6. Must have no planned changes in outpatient psychiatric treatment regimen, which can
include psychotropic medications and/or psychotherapeutic interventions, two weeks
prior to enrollment and throughout the three weeks of training and post-training
assessment.
EXCLUSION CRITERIA:
Exclusion criteria both Interpretation Bias Training and Cognitive Behavioral Therapy
Studies:
1. The individual exhibits any of these cardinal bipolar symptoms:
1. Elevated or expansive mood.
2. Grandiosity or inflated self-esteem.
3. Decreased need for sleep.
4. Increase in goal-directed activity (this can result in the excessive involvement
in pleasurable activities that have a high potential for painful consequences).
5. A history of hypomanic or manic symptoms that occurred in distinct episodes
lasting more than 1 day.
2. Meets DSM 5 criteria for schizophrenia, schizophreniform disorder, schizoaffective
illness, Autism Spectrum Disorder, or posttraumatic stress disorder.
3. IQ<70
4. The symptoms are due to the direct physiologic effects of a drug of abuse, or to a
general medical or neurological condition.
5. Meets criteria for alcohol or substance abuse three months prior to enrollment.
6. Meets DSM 5 criteria for current major depressive disorder. The rationale for the
exclusion of youth with MDD is because the two novel interventions being tested are
contraindicated for those with major depressive disorder. However, there is no
contraindication to participation for those with treated/resolved or remitted major
depressive disorder; only those with a current diagnosis need to be excluded.
We found this trial at
1
site
9000 Rockville Pike
Bethesda, Maryland 20892
Bethesda, Maryland 20892
Phone: 800-411-1222
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