# Facebook Live: Childhood Irritability

November 7, 2023

## Transcript

**MELISSA BROTMAN:** Hello, everyone, and thank you for joining me today for this discussion on childhood irritability. My name is Dr. Melissa Brotman. I'm the Chief of Neuroscience and Novel Therapeutics at the National Institute of Mental Health Intramural Research Program, or NIMH for short. As we know, many psychiatric disorders first present during childhood, and irritability and anxiety are among the most common clinical problems in youth. The goal of my research group is to develop brain-based treatments for children who struggle with emotional and behavioral problems. During the next half hour together, we're going to talk about the symptoms of irritability, why it's important to study irritability, NIMH-supported research in this area, and some new treatments for severe irritability in youth. I'll also use the last 10 minutes or so to take some of your questions. So please enter them as comments under the live stream below, and I'll do my best to answer the questions before the end of our session today. It's important to note that during the event today, I cannot provide specific medical advice or referrals. Please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. If you need help finding a provider, please visit nimh.nih.gov/findhelp. If you or someone you know is in crisis, please call or text the 988 Suicide and Crisis Lifeline at 988. Visit 988lifeline.org** for more help and information.

**MELISSA BROTMAN:** The Lifeline provides 24/7 free and confidential support for people in distress, prevention and crisis resources for you or your loved ones and best practices for professionals in the United States. Okay. So let's get into our discussion for today. First, as I mentioned before, it's important to know that for many adults with psychiatric disorders today, their symptoms first presented during childhood and adolescence. The symptoms may or may not have been recognized or addressed at that time, and that's why early assessment and intervention is so important. Irritability, similar to other emotions and feelings, can be associated with psychiatric disorders. Irritability also presents in children and adolescents and adults without a clinical diagnosis. Everyone experiences anger and irritability. That is, irritability is developmentally normative. That means there are certain times in development when irritability tends to be more common. We know from our research and with talking with parents and providers that irritability tends to peak during the preschool years and also during adolescence.

**MELISSA BROTMAN:** Okay, so what is irritability? Irritability can be described as a low threshold for experiencing anger or frustration. We think about irritability as presenting in two ways, phasic irritability and tonic irritability. Phasic irritability is a behavior that a parent, teacher, or friend would be able to see. Phasic irritability is defined as a behavioral or temper outburst of intense anger. A child yelling, screaming, slamming a door, stomping, or throwing a toy or iPad would be examples of phasic irritability. The other presentation is tonic irritability. Tonic irritability is defined as a persistently angry, grumpy, grouchy, or cranky 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, or DSM, has used the classification of disruptive mood dysregulation disorder, DMDD, as a mood disorder that presents with both behavioral outbursts and a chronically grumpy and angry mood. 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.

**MELISSA BROTMAN:** Youth who struggle with DMDD experience significant problems at home, at school, and often with their peers. Now, it's important to note that irritability also presents in many 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 disorders. We also have to acknowledge that life and environmental stressors can increase or decrease a child's level of irritability. When making a clinical diagnosis, it's important for the provider to consider the context, any recent changes or transitions, and the developmental level or age of the child. So what are some common situations that can lead to severe anger and irritability in youth with DMDD? Common triggers are: a child asking for a specific object or reward, such as a toy, treat, or screen time, and being told no, when a limit is being set, or when a child has to transition from a preferred activity, like playing a video game, to a less preferred activity, like doing homework or household chores. Many children get angry and upset, but children with DMDD have severe and impairing temper outbursts that influence their everyday life and activities.

**MELISSA BROTMAN:** How can you tell if your child's irritability is clinically worrisome? I suggest that parents consult with mental health providers. A therapist, psychologist, psychiatrist, or pediatrician can determine if the child's irritability is causing functional impairment. The practitioner may ask about the frequency of the anger and irritability. That is, how often the child is experiencing anger and irritability. The duration of the anger. That is, how long the child remains angry when an event occurs and the threshold of the anger. That is, how easily does the child get angry, annoyed, or irritable. To assess functional impairment, the clinician may ask the child's family about their relationships, peer relationships, and the child's ability to get along with others in school and with teachers. So now let's talk about exposure therapy. Exposure therapy is a behavioral technique for the treatment of fear and anxiety disorders. And we know from brain science that this treatment engages a specific brain-based circuit. During exposure therapy, we create a hierarchy of fear-inducing stimuli, and patients repeatedly practice facing the feared object or situation in a safe way. Exposure therapy is extremely effective for anxiety disorders.

**MELISSA BROTMAN:** Thinking about the effectiveness of exposure therapy for treating anxiety made me wonder if exposure to anger-inducing events could lead to a decrease in anger and irritability in youth with DMDD. For the past five years, based on these principles of exposure, my research team and I developed and published a treatment for children who struggle with chronic and severe irritability and temper outbursts. Our cognitive behavioral therapy is based on the idea that exposing youth to their specific anger-inducing triggers in a safe, therapeutic context will help the child develop skills to inhibit their maladaptive responses by learning to tolerate the uncomfortable emotions associated with anger. Our 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 of 1 or 2 out of 10. Then, the clinician will elicit medium-level anger of exposures at a level of 4 or 5. And then, we will talk about situations and events that make the child very angry at a level 8 or 9. While doing this, the clinician often asks the child to talk about how they know when they're angry and to draw where they feel anger in their body. After talking about what anger feels like, then the child will practice a low-level exposure that makes the child a little angry.

**MELISSA BROTMAN:** This may 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. While we're practicing getting angry, we encourage the child to notice the feelings in their body, tolerate the physical feelings associated with being angry, and practice okay and not okay ways of expressing anger. The child learns that over time and with practice, the anger or bad feelings go down. In working with children, the therapist asked the child to generate an anger pro and con list to see how the child sees their anger as helping them and in getting in the way of what they want to do. Therapists ask the child what they want to work on most and what they want to work on first. Children often say they wish they could control their anger more and have lost friends, privileges, and other things because their anger has gotten in the way of them doing something fun. 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. Both parents and children provide consent and ascent, respectively, before starting treatment.

**MELISSA BROTMAN:** The treatment is as much about having the child practice manage feelings associated with anger as it is about teaching parents strategies and skills to manage their child's outbursts and irritability. The parents are typically eager to have their children learn skills to deal with their anger and irritability, and parents are often involved in the initial discussions around developing the anger hierarchy with the child. As a part of 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 reaction 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. We just published a paper testing this therapy ** with 40 children, and we found that children's symptoms of anger, temper outbursts, and irritability decreased over the course of treatment. So now I think it's a good time for me to pause and take some of your questions.

**MELISSA BROTMAN:** So one question I see here is, can basic irritability be similar to autism? This is an excellent question. We see many kids with a primary diagnosis of autism spectrum disorders exhibit symptoms of irritability. The irritability often can be elicited in response to changing a routine or having to violate some rule or rigid wish or behavior. The way we deal with anxiety and irritability in our treatments here is we are not primarily focusing on children who have a primary diagnosis of an autism spectrum disorder because there are other treatments in the community that specifically target the symptoms associated with autism. At the same time, I do want to highlight that irritability is transdiagnostic in that we see irritability presenting in children with autism as well as in children with major depressive disorder, attention deficit hyper, oppositional defiant disorder, and other mood and anxiety disorders.

**MELISSA BROTMAN:** Another question I see here is, is childhood irritability more common in girls or boys? This is also a really interesting question. We have found in epidemiological studies - that is, when we do studies in the population - in the community, there actually are not differences in the presentation of severe irritability in boys and girls. That is, when we reach out to the community and look at all the children in, say, various schools or in community clinics, the rates of irritability tend to be similar. At the same time, here at NIMH, where we're recruiting kids to be in our treatment here on campus in Bethesda, Maryland, we tend to enroll kids that tend to be more boys than girls. So there's a bit of a difference in terms of what may be present in the community and what families are reaching out to us and asking for treatment.

**MELISSA BROTMAN:** Another question, did the COVID-19 pandemic increase the rates of childhood irritability? This is actually also a very interesting question that my lab pursued during the acute stay-at-home orders during the COVID-19 pandemic. And in fact, as one may imagine and may have experienced in one's home life, with parents and children and many people forced in the home environment, the rates of anger and irritability and family discord did tend to increase during those acute stay-at-home orders. So we did see an increase of anger and irritability and parent-child distress, particularly for parents who are working with younger children and had to work with those children during those-- ability to do schoolwork from home. So we did see a bit of an uptick in anger and irritability and family distress during that COVID time. We're continuing to focus on that and see what we can learn from those family dynamics to kind of help prevent things like that in the future.

**MELISSA BROTMAN:** Question number four, how is irritability different from ODD? This is also another excellent question. As I noted a moment ago, irritability is present in youth who have a diagnosis of oppositional defiant disorder. And in fact, it's quite common in youth with oppositional defiant disorder. One of the differences we see when we talk about irritability is there, as I mentioned, two kinds of irritability, the tonic irritability, that baseline, angry or grumpy mood, as well as the phasic irritability, that is that behavioral manifestation of anger. In youth with oppositional defiant disorder, we tend to see more of that reaction, that phasic irritability in response to some specific event. So while kids with oppositional defiant disorder can experience that baseline, irritable, grumpy, tonic, irritable mood, what we see is kids with oppositional defiant disorder tend to be enriched, that is, tend to present more with more of that phasic irritability or a reaction to a specific event that makes them very angry or frustrated.

**MELISSA BROTMAN:** Question five, can you talk about the importance of ruling out PANDAS and how to rule out infection-associated immune-mediated neuropsychiatric disorders? This is also a very interesting question. And there's a big line of research actually growing out of the National Institutes of Health, the National Institute of Mental Health, but Dr. Susan Swedo that identified PANDAS and specific psychiatric and behaviors associated with following an acute immune response reaction. Typically, one sees those as symptoms that often mirror obsessive-compulsive disorder, repetitive motions, tics, and other kind of more motoric repeated behaviors. We have not found in our work, specifically, that the kids with irritability that we're seeing are having an acute onset following some type of immuno response. That is, the kids we're seeing when we talk to their parents, they say they have noticed irritability, grumpiness, and temper outbursts for as long as they can remember, dating back to preschool. That is, if we heard a family call and say, all of a sudden, after this infection, this strep infection, we're now all of a sudden seeing a very different manifestation of anger, then that would make me think, oh, this is different than the group of kids that I'm studying. I think it's possible that there may be some type of irritability or anger acute response to these infections.

**MELISSA BROTMAN:** However, that's different than the group of kids that I'm focusing on who have kind of a lifetime presentation that has not acutely emerged from some infectious process. Question six, for providers who work in crisis units, does exposure therapy work with suicide prevention or reduction of risk of suicide. We have not tested exposure therapy for suicide prevention. So the most direct answer to that is no, and we don't know. From my understanding and my conceptualization of the anger exposure we're doing, exposure to suicide and suicide thoughts is not part of the theoretical brain-based conceptualization upon which I built this treatment. It's interesting to think about from the perspective of tolerating negative thoughts or desires associated with suicide. However, I would not say that exposure for suicide prevention is anything that has been robustly test or investigated at this time.

**MELISSA BROTMAN:**Question seven, how do parents identify if parents' emotional neglect is leading to child irritability as in seeking attention tendency? So again, this is a really sophisticated question. And as I alluded to, I focused on the exposure therapy work whereby the clinicians are working directly with the child to expose the child to anger-inducing events and practice having a response. Another big component of the treatment is working directly with the parents. And while we work with the parents, what we do is kind of a full assessment to get a sense of what the nature of that relationship is. Is the child feeling like they get more attention from the parents from having these anger and irritable outbursts? What can we do to change that? Is that something the parents are aware of? Is that something that the parents and children agree? These are all early discussions that we very much focus on and talk about at the beginning of therapy when we're setting our goals for the next 12 weeks.

**MELISSA BROTMAN:** How does excessive exposure to social media contribute to childhood irritability? This is a really important question that I actually can't answer. And I think it's something, an area of work that we as a field really need to focus more on. I can say from my personal experience working with children and treating children with severe irritability, a common trigger of irritability is having a child have to stop using, say, their Instagram or TikTok feed, stop and switch to a less preferred activity. But that's more in the context of doing something the child wants to do, having to stop that task, and then switch to another activity that they may not find as appealing, such as doing homework, brushing their teeth, or some sort of household chore. That's generally engaging in social media writ large, but I don't know specifically about the time spent on social media and how that may or may not be related to some of the mood disorders we're seeing in kids.

**MELISSA BROTMAN:** Question nine, is irritability inherited or run in families? This is also a really interesting question. There are several epidemiological genetic studies that we've been engaged in, where we look at the extent to which irritability is familial, that is, travels within families, and heritable, that is, may be specifically associated with genes. The overall answer is that irritability is as genetic, as heritable, as familial as anxiety disorders. So when you think of anxiety running in families, irritability runs in families to a similar way as, say, anxiety does. Last question, in school settings, are there any quick tips that teachers can use? Yes, this is a question I often get when I'm working in schools and talking with school staff. There are many really strong programs that schools have in terms of fast passes and planning in advance. I think the key here is transparency and having the family, the child, and the school working together, acknowledging where the weaknesses are in the system, and then providing the child with skills to help them flourish to the best of their ability. One of the strategies I've heard about is these fast passes, where if a child is feeling overwhelming emotions, they have the ability to show a fast pass and go directly to their school guidance counselor or some other trusted adult outside of the school classroom to get support and express their needs.

**MELISSA BROTMAN:** So it looks like we've reached the end of our discussion today. I want to thank you all so much for joining me and for all of your important questions. Again, if you or someone you know is in crisis, please call or text the 988 Suicide and Crisis Lifeline at 988. Visit 988lifeline.org** for more help and information. And if you'd like to learn more about my clinical research studies at NIMH, please visit nimh.nih.gov/joinastudy. And thank you all again for your time and attention. Have a good day. Thank you.