Psychological Treatments for Youth With Severe Irritability.

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 and adapt the in-person manual to being a hybrid intervention. To accomplish this objective, we will utilize a within-subjects multiple baseline design. 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 seven 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 irritability, 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