A new study analyzed the role of behavioral therapy in children and adolescents to manage persistent states of anger and irritability that are, according to researchers, much more than a fleeting state of annoyance. If these temper outbursts are constant and increasing in intensity, they can be considered clinically impairing.

Clinical irritability affects a child’s daily life and, if not diagnosed and treated, can continue to cause problems in adulthood. Although this type of extreme anger is one of the main reasons parents or caregivers seek psychiatric care for minors, it is understudied compared to other childhood mental health disorders.

Evidence-based treatments for clinical irritability are also lacking, indicates the new article by researchers from the US National Institute of Mental Health (NIMH).

Researchers successfully used exposure-based cognitive behavioral therapy (CBT) to treat severe irritability in children. This promising development underscores the importance of personalized, nonpharmacological interventions in this area of child psychiatry.

This study focused on severe, incapacitating irritability and temper outbursts in youth. All children get angry or irritable sometimes. But severe irritability is more serious and can cause problems at home, in school activities, and with friends.

Anger and outbursts are part of many mental disorders, but they are key symptoms of disruptive mood dysregulation disorder (DMDD). DMDD is diagnosed in children and adolescents who show constant irritability, frequent anger, and intense temper outbursts. The most common symptoms are:

The symptoms of DMDD are severe and require treatment. Children with this high level of irritability get angry often and in a way that is disproportionate to the situation and their age. When they are angry, they have temper outbursts, usually with high motor activity and verbal or physical aggression.

How do researchers treat severe irritability in children? Researchers tested exposure therapy , a novel treatment for irritability that was developed in a laboratory and is highly effective for anxiety. In this pilot study, scientists looked at the effectiveness, acceptability, and feasibility of this therapy to treat severe irritability.

The research involved 40 children between 8 and 17 years of age who had at least one of the following symptoms: chronically irritable mood or severe temper outbursts.

All children participated in 12 exposure-based therapy sessions, some alone and others with their parents.The patient portion focused on increasing tolerance to frustration. The therapists carefully exposed the children to anger-provoking situations, gradually progressing through a hierarchy specific to that child.

Some examples could be taking away a favorite item (for example, turning off a video game or taking away an iPad) or starting a disagreeable activity (for example, brushing teeth or doing homework). Researchers worked with the child to teach them to tolerate and constructively respond to their feelings without an anger outburst.

The parent portion focused on parent management skills. Parents were taught to actively ignore their children’s anger outbursts to stop reinforcing those behaviors. Instead, they learned to focus on and consistently reward positive behaviors. Children were randomized to be observed for 2, 4, or 6 weeks before starting treatment.

The clinical observers did not know when the active treatment began. This observation period allowed researchers to confirm that the symptoms changed only after treatment began and were not explained by the clinician’s expectations for the treatment.

Clinicians, children, and parents rated the child’s irritability symptoms and their overall functioning during the observation period and treatment, as well as 3 and 6 months after treatment. They also rated symptoms of depression, anxiety, and ADHD for comparison. The acceptability, feasibility, and safety of the therapy was determined through study dropout rates and adverse events.

Did exposure-based CBT help children with severe irritability? Symptoms of irritability significantly decreased during treatment, according to reports by clinicians, children, and parents. Overall functioning also improved: toward the end of treatment, 65% of children showed significant improvement or had recovered. 

Symptoms did not reappear after the treatment ended and, in fact, the improvements achieved through this therapy were maintained at the 3- and 6-month follow-ups.

No families left the study after treatment began, which suggests that the exposure therapy was acceptable and feasible. Additionally, no adverse events were reported, which supports the safety of using exposure therapy with children.

Researchers plan to test and refine exposure therapy in larger, controlled clinical trials to make progress in treatment for children with severe irritability and their families.