Community Conversation Webinar Series Video: Is Your Kid Often Angry, Cranky, Irritable

Transcript

RAMARIS GERMAN: All right. Well, let's get started. Thank you. Everyone for coming today. We are so delighted that you're here. Firstly, I want to introduce myself. My name is Dr. Ramaris German, and I'm a clinical psychologist here at the Neuroscience and Novel Therapeutics Unit (NNT) at the Emotion and Development Branch of the NIMH.

RAMARIS GERMAN: I do want to highlight that this is one of several talks that we will be providing to the community in the Community Conversations Webinar series. So, I invite you to look out for other talks in the future, as there will be other ones for topics that are a little bit different, but probably would pique your interest.

RAMARIS GERMAN: Another piece I did want to share with everyone. I have a few Slido polls, so please make sure to. You can use your phone. There'll be a QR code for that. So please participate in the polls, as well as we will share some resources through the chat function as well.

RAMARIS GERMAN: So, just to be clear, today, we're going to be talking about irritability. And I'm going to discuss a couple of pieces around what irritability and youth looks like, as well as talking about treatments.

RAMARIS GERMAN: Before we get started. I want to give first a disclosure. I have no conflicts to disclose. All the research and the information I'm providing here has been supported by the NIMH intramural research program.

RAMARIS GERMAN: This presentation should not be considered medical advice for any specific person. So please talk with your healthcare provider about the benefits and risks of any treatment as well as you can visit the FDA website for the latest warnings, patient medication guidelines, and any newly approved drugs. So again, this is not to be taken as medical advice. Thank you.

RAMARIS GERMAN: I want to start by getting a sense of who's here? Just to see if there's any pieces I could potentially kind of highlight for those individuals that are here. Specifically, so feel free to put your phone up. To the QR code. I hope everybody can see that. And then kind of click, if you're sort of if these categories do not fit with you, I apologize. If I didn't make an ex in a very ex inclusive list. There is the other category. So, I just want to see more or less who's present today?

RAMARIS GERMAN: Just want to give people a little bit of time to make sure they can participate if they choose to. Looking at those numbers. And who's present.

RAMARIS GERMAN: Excellent, excellent.

RAMARIS GERMAN: Alright. So, it's looking like predominantly mental health care providers so welcome. We'll be speaking with, you know, potential colleagues, then, caregivers as well. Other. I guess that could be a wide range of individuals. Again, I said, I could not make an exhaustive list. And then family members of a child with irritability. So yeah, mental health provider, healthcare provider and some researcher scientists. We are at the NIMH.

RAMARIS GERMAN: Excellent! Oh, person with irritability as well as teacher. Okay. So, we've got a little bit of everything. Okay? Good to know who's here.

RAMARIS GERMAN: Thank you. Alright.

RAMARIS GERMAN: So I want to give you an outline of what we're going to be discussing today. First, I want to start with what is clinical irritability? So, getting to kind of like the crux of what most of you're probably here for what - to understand and know what clinical irritability is. Then we're going to talk a little bit about treatments and interventions that are out there.

RAMARIS GERMAN: And then I want to introduce you to this really cool new treatment that we've developed here one of the things I mainly do here which is an exposure-based therapy for irritability.

RAMARIS GERMAN: So, let's start with the why. Just to kind of give you some context in general, irritability is one of the most common reasons that children are referred to treatment, and there are a few effective treatments for children with irritability.

RAMARIS GERMAN: Developing intervention is particularly important because of the added DSM, which is the diagnostic and statistical manual, that most of us in particular, I'm sure those mental health providers that are here very familiar with it's what we use to assess and diagnose children and adults as well. So DSM created added a diagnosis of disruptive mood dysregulation disorder which is characterized by the type of irritability that I will be discussing.

RAMARIS GERMAN: And in order to address this diagnosis, essentially like the symptoms that could be seen in the DMDD, so the disruptive mood dysregulation disorder diagnosis, our team has developed a treatment to help address the type of irritability present in this disorder.

RAMARIS GERMAN: So let's start with a little case example, just to highlight who our kiddos are. So, let's talk a little bit about Junior. So Junior is a 9-year-old boy that presents to us in our clinic. He's had chronic grouchiness and irritability temper outbursts all his life.

RAMARIS GERMAN: So at age six, Junior was suspended from school because of his behaviors and was then subsequently diagnosed with attention deficit hyperactivity disorder.

RAMARIS GERMAN: So at that time he was also put on medications, but he continued to have chronic grouchiness and temper outbursts when frustrated.

RAMARIS GERMAN: So they tended to be mostly verbal, but sometimes physical, and they occurred about daily at home with parents, and then weekly at school.

RAMARIS GERMAN: So, despite all of this, it seems like his grouchiness and his temper continued, despite being in treatment, so much so that it limited his ability to function at school. So, he was diagnosed with disruptive mood dysregulation disorder.

RAMARIS GERMAN: So that's just kind of gives you some context and to encapsulate what this could look like in children.

RAMARIS GERMAN: So let's talk a little bit about what is irritability, particularly what is clinical irritability, so irritability is the tendency to anger compared to similar peers. Their age, that can reach a pathological or clinical level. So, it's relative to the age of the child compared to other typically developing children.

RAMARIS GERMAN: There's two facets to irritability in general that we look at particularly the emotional component and the behavioral component. So, the emotional component is this irritable mood sort of that grouchy, grabby state that can happen for most of the time, and then the behavioral component of what we technically call temper outbursts. So, sort of this inability to stop themselves from doing these aggressive behaviors when they get frustrated, or when they get angry. So, as you can see here in the little image, there's a child kind of throwing their toy out in anger and breaking it. So again, irritability would have both of these components.

RAMARIS GERMAN: How do we determine whether it's reaching a clinical level. We look at three domains. When we look at that, we look at the frequency. So, children with severe irritability, they get angry more often than most children, so they tend to get angry a lot over the week. They tend to stay angry for longer, so say 30 minutes to an hour, possibly a whole day they can be angry for, and then the threshold so little things can get them upset compared to same age peers. So, you know sometimes what might be upsetting to a 4-year-old. Right? Can be one thing. But then you have a 13-year-old who's getting upset for something similar? Doesn't seem right.

RAMARIS GERMAN: The other critical piece about clinical irritability. When we think of psychopathology, or we think of symptoms that could potentially be in problem. Right? We need to think about how it affects the child in terms of their ability to function. So, we think about it in multiple domains. We think about the home, the school, or with peers.

RAMARIS GERMAN: And in this case, if we want to conceptualize irritability to being at a clinical level, we need to think about whether it's affecting multiple areas. And one critical piece, too, is about the context, right? So obviously, impairment is assessed based on the child's age. Their developmental level as well as cultural context is going to be really important.

RAMARIS GERMAN: So, what is a temper outburst? I kind of gave you a snapshot of what that was. So, these are some images of what a temper outburst can look like. Right? We see here, Junior sort of raising their arms in anger or throwing their desk around, and then we see a couple of their children seemingly screaming or throwing themselves on the floor. So, these are different types of behaviors that can be exhibited or manifested when a child is in this state.

RAMARIS GERMAN: So, I want to then use the Slido poll as well to ask you again. So, what does its mild temper outbursts look like? What are some behaviors that one could see? Let's start with mild.

RAMARIS GERMAN: A mild temper. Outburst. Okay? Yelling, stumping, pouting, crying, facial expression, mild, stomping feet, frustrated, angry face. Shutting down. Okay. Tell me what a moderate would look like refusal to follow instructions. Set heavy size. I like, very okay, good, good whining. Lashing out, at others. Yelling, yelling and crying seems to be number one answer. And then let's see what a severe look like shutting down something. Feet. Pouting hitting, won't listen, throwing objects, yes. Breaking things excellent. Violent. Absolutely, absolutely, disruptive. Hitting walls, running away. Fighting. Crossing arms, aggression towards objects. Throwing things, slamming doors, okay. Excellent. Self-injury. Physical hurting, throw yourself to the ground. Making verbal threats. Excellent, excellent. Okay, so yeah, I mean absolutely, you can see how these very disruptive behaviors can manifest themselves when children are frustrated or angry at what a temper outburst tends to look like, right? Wanna give more chance for people to finish typing, slamming doors.

RAMARIS GERMAN: Excellent, excellent. Okay. So, I think everyone has a sense for what this looks like, right, whether you've seen it in others, maybe not yourself, sometimes right, whether you've seen it in others or youth. You know what this looks like.

RAMARIS GERMAN: So, let's see how we did. So, let's talk about it now, what is the temper outburst so mild, snapping, talking back, arguing, name calling. This would be in the mild range.

RAMARIS GERMAN: Yelling and screaming, which was our most common answer. That's in the moderate range. So, we consider that moderate for our group.

RAMARIS GERMAN: Verbal threats. That was literally something that somebody inputted.

RAMARIS GERMAN: Clenching fists, racing arms to hit. That's in the moderate range and throwing things down in anger. Right? Not necessarily with the intent to destroy property but throwing them down in anger.

RAMARIS GERMAN: And then severe. I think most of us had a sense for what severe would look like using objects in a way to harm physical displays, breaking belongings.

RAMARIS GERMAN: Punching, kicking. I'm thinking of vandalism, destruction of property shoving, slapping. So, you know, I think you all had even a more exhaustive list, but just giving you a sense for sort of where the temper outbursts sort of ranges in terms of mild, moderate, and severe.

RAMARIS GERMAN: So now I want to give you another Slido poll. I want to get a sense for what are some common anger or frustration triggers for kids?

RAMARIS GERMAN: What are some things that usually make kids angry or hmm. Yeah. The word. No.

RAMARIS GERMAN: Not getting their way. Yes. Lack of control, unfairness, folding laundry. Good one, there'll be an example of that later. Academic demands, embarrassment not having a choice, being told, no chores, removing items.

RAMARIS GERMAN: Feeling, ill or scared, time for bed, sensory overload. Perceived injustice similar to unfairness. Right?

RAMARIS GERMAN: Removing privileges. Yes, absolutely.

RAMARIS GERMAN: Not getting their way. Getting off videos. Don't understand the homework. Thank you. That's a really good one there, too.

RAMARIS GERMAN: Not getting their way again, different limit setting, confused, perfectionism, losing friend, fights, rivalries, not heard. Emotional dysregulation.

RAMARIS GERMAN: This is fantastic. You're all very, very good. Excellent.

RAMARIS GERMAN: Okay, exactly. Jealousy. Good one.

RAMARIS GERMAN: So, these are some of the things right that make kids angry. I think we're all aware of sort of what that looks like in the realm, you know, particularly being told "No", setting those limits, you know. This perceived injustice or unfairness so that would be another one. Transitions. Yes, absolutely. We talk a lot about transitions, sharing, right, not being able to share. So, I think you've got most of it there. So, let's talk about task endurance deficit. I like that one technology restrictions again.

RAMARIS GERMAN: So, you'll see they're all here. So, let's go through them ourselves. So, you predicted, of course, limiting screens. Children do not appreciate that. And then, having to do homework particularly, you know, myself. So homework gets confusing, or maybe a little bit harder than the child is able to complete or doesn't understand. You know. And then I saw transitions was a really big, common response. So, transitioning from going from screens and preferred activity to going into doing homework, which is a non-preferred activity. So that would definitely be a trigger for most kids, in terms of, you know, leading to some sort of manifestation of anger. Whether it is, you know, the temper outburst.

RAMARIS GERMAN: Obviously eating their vegetables. We all have to. But some kids definitely would throw a tantrum, particularly if they were expecting pizza, right? So, expectations not met. So, if they wanted pizza, or you know, chicken nuggets, and you provide them with a plate looking like this, you might get a temper outburst.

RAMARIS GERMAN: You know. I think also of like restrictions for teenagers, let's say, on social media, or any of that right? So, thinking about those pieces. Obviously, your activities of daily living slash your routine. So that's one of the things that I tend to assess when I ask about impairment. Talk to me about your mornings, talk to me about your evening and then I try to gauge from that. What are those triggers like? Bedtime routine, even washing their hair, right? Go taking a shower. What does that look like for you?

RAMARIS GERMAN: Yes, having to share particularly, let's say, with siblings, whether it's in both cases - there's a screen, fighting with siblings about sharing a toy or sharing screens that can get a little tricky, and siblings always complicate it a little bit more. The system right in terms of how to respond and how to handle children who have irritability.

RAMARIS GERMAN: Having to do chores, as well right, having to play their instrument or practice. You know whether it is soccer, basketball, or the flute or piano lessons having to practice, and then, you know, sometimes at the grocery store, not getting them the snacks they want, or at the toy store, if they want, like all the toys.

RAMARIS GERMAN: You know. And it's interesting even sometimes with sports and their extracurriculars. There are times when their team will win, and the child will come to me and say, yeah, but they didn't pass me the ball enough. Right? So, it's really about their perspective. So, to the child, it makes sense as to why they're angry. So, it's really about their perspective, about what was the goal that I was trying to achieve. That was blocked.

RAMARIS GERMAN: What was my expectation? Right, change that to what was actually delivered. You know, what did I actually want to do? Being told? No, right. What was the no in this situation? So those are some common triggers that we see often with the kids that come to our to our studies.

RAMARIS GERMAN: So, there's that second component, right? We just talked about the behavior component. So, we're talking about the mood component. So that chronic irritability, right? So, I think of Squidward and angry cat when I think about chronic irritability. So, what does that? What does that look like? So, not specific outbursts? Right? So, outbursts. Kind of you have a trigger, and then it comes up. And then over time eventually comes down for our kids. That coming down takes a long time, right? I saw emotion regulation, emotion dysregulation, and that is one of the deficits or challenges that our kids tend to have. But general grouchiness. In this case this is different. This is about the mood. I kind of create a pie chart and ask, like, what percentage of the pie throughout the day would you say your child is irritable, angry, or grouchy?

RAMARIS GERMAN: Right? So, these are some of the words that we hear and sometimes from kiddos grumpy, grouchy, crabby. I had a kid whose nickname was Crabby Patty.

RAMARIS GERMAN: Cranky, Moody. So, these are some of the descriptors that we tend to hear about that mood component piece. So, you know, with parents, I will tell you that at least 50% of the time when we do these assessments. Clinical assessment, we hear, I feel like "I'm walking on eggshells." I also think of like double Dutch, and like having to figure out a way to get in there somehow because they feel like they have to approach them in the right way or otherwise they're going to have this big blowout. And of course we're trying. It's so aversive to the family, and very disruptive to let's say the morning routine, or we're trying to get out. We're trying to get to work. We're trying to get you in the car. So, it's this sense of constantly being sort of vigilant by the parents to avoid this chronic mood.

RAMARIS GERMAN: And then what happens is that then the parents and caregivers in general tend to make accommodations right in terms of trying to avoid children being. in the state, because it is so disruptive, and they do have to get to work, and things need to happen. The child has to get to school, right? So essentially, what happens is they tend to miss out on life, and it obviously leads to a decreased quality of life. You know. I've heard parents having to drive in two different cars just to avoid this, or missing out on family functions, right? Because the child tends to have an outburst, let's say, when they're around their cousins, or when they're out in particular places, or in the summer, not being able to go to the pool because the child tended to have a lot of fights there. So, thinking about that, you know, it's very sad to hear how people are missing out on just general activities that are important for children to thrive and grow and develop socially, intellectually, and emotionally right?

RAMARIS GERMAN: So, why is it important to study irritability. So, you know, so far, we spend some time highlighting and defining irritability. But why is it important to study it? And obviously we do that here, and that's particularly the majority of my work.

RAMARIS GERMAN: So, you know, like I said already, it's one of the most, the main reasons why children are referred to psychiatric care.

RAMARIS GERMAN: You know, there's a couple many, many studies on this, and particularly some longitudinal studies. I chose to use Copeland, et all, 2014 to talk about irritability leads to adult impairment.

RAMARIS GERMAN: As well as you know, sort of leads to anxiety and depressive disorders as adults. Academic problems being impoverished as well. You know some of these are not listed here, but they talk a little bit about involvement, obviously, with the justice system as well as low education, attainment, and ultimately as well, suicidality.

RAMARIS GERMAN: So, thinking about those pieces and what's really critical, particularly as we move on to talk a little bit more about disruptive mood dysregulation disorder is that it's highly likely for a lot of kids who tend to have disruptive mood might have other disorders. So, it's difficult to disentangle sort of how all of these psychological symptoms sort of play together in a way to lead to these negative outcomes.

RAMARIS GERMAN: So essentially, again. This is why it is important to identify the symptoms that would then fall within the rubric of this disruptive mood. Dysregulation disorder that again was created into and was developed or established in 2013, and the Diagnostic Statistical Manual.

RAMARIS GERMAN: And I just want to be clear that in terms of the DMDD diagnosis, it's reported to have a prevalence of about 3% in the population. So, let's walk you through what that looks like. So, there's a better understanding for all of us about what are the actual symptoms of a child who may have this diagnosis.

RAMARIS GERMAN: So, let's start with the temper outburst, right? That behavioral component we talked about. So, what does that look like? So severe? So, remember, we made the chart, and I asked you, what does severe look like so severe, recurrent outbursts, so it could be verbal rages or physical aggression towards people or property, out of proportion. Right? It's more than it needs to be. Sort of again that 4-year-old compared to that 12- or 13-year-old out of proportion, let's say, for the situation, and inconsistent with developmental level thinking about what's appropriate for a 12-or-13-year-old you know, and what's appropriate for a 4-year-old. So, what might be appropriate for real is not so much for a 10-13-year-old and must happen at least three or more times a week. So that's a temper out criteria.

RAMARIS GERMAN: Remember that Crabby Patty, Squidward, angry cat, right? That mood component. So, when they have the pie chart, the majority of that pie chart in terms of what your week looks like, in terms of your child's mood, irritable or angry, most of the day. So, I say at least 51% of the time. So, most of that pie is taken up by this feeling of irritability in terms of impairment. It must be present in at least two out of three domains, so we categorize the domains as home, school, and with peers. Severe in at least one of them so, and at least mild in another, so it has to reach a clinical level. To reach a clinical level, it must be severe, at least in one, and present in at least another present for at least 12 months. So how long has this been going on for, right? There's sometimes there are events that happen that can lead children to have very strong reactions and those reactions can look like this. But you must be very cautious in terms of, you know - are there any participants?

RAMARIS GERMAN: When did this start? How long has it been going for? Have there been any breaks? Sort of what's the trajectory of the of the symptomatology and the development of the disorder? And then, you know, you want to think about development, right? You want to think about whether you know we're talking. If we're talking about a preschooler or 4-year-old, 5-year-old, you know. Some behaviors might be appropriate might maybe be high for a typically developing kid but might not be reaching those clinical levels. And then once you reach age 10, then you're talking about things like puberty. And there's other factors, right and other social demands that come into play. So, we want to think about this diagnosis. Where these symptoms have been present prior to age 10, but not before six. And then, of course, we want to be mindful about this not being something like bipolar disorder. So, we want to sort of exclude for mania or hypomania.

RAMARIS GERMAN: So, I highlighted that there's two main cores DMDD criteria, and that is that irritable mood 50% of the time. Another piece of that it must be noticeable by others, not just parents. So, you're sort of getting reports from peers or from your peers, parents or schools, right? They're not being invited to places, because you can tell he's either grumpy pants or she's a grumpy pants temper outbursts as well need to be present like we talked about.

RAMARIS GERMAN: So, I do want to highlight one piece. So, I just spent most of my time talking about disruptive mood dysregulation disorder, and like I said, the treatment I'm going to discuss is something that was developed for the type of irritability present in disruptive mood dysregulation disorder.

RAMARIS GERMAN: however, irritability is present in multiple diagnoses. I also mentioned that it is rare for disruptive mood dysregulation disorder at times to not have other comorbidities or other disorders or symptoms of disorders that are present. So, what's interesting about irritability is that it's highly comorbid. And it's present in multiple diagnoses. In fact, irritability or anger appears as a symptom in about 20 conditions in the DSM.

RAMARIS GERMAN: Including disorders characterized by aggression and irritability, is a multi-faceted, dimensional, construct or symptom. So, we must be thoughtful of that so

RAMARIS GERMAN: it is present in bipolar disorder, Major depressive disorder, ADHD, generalized anxiety disorder, separation anxiety, social anxiety, panic disorder, PTSD, ODD, conduct disorder, and autism spectrum disorder. And like, I said, it's potentially present in more, and it shows up. But I just want to highlight a few, the ones in blue. That is one of the criteria, in fact, a form of anger or irritability is a criterion to meet diagnosis for these disorders.

RAMARIS GERMAN: So again, I want to highlight that it is very important to have your child be assessed. Did you think your child does have irritability at a level that is impairing or clinical? And it is important for them to be assessed, in part because it's also important for them to identify what is driving it, right. What is driving this irritability? Because, knowing what drives the irritability is also going to be helpful in terms of knowing how to treat it so. For example, if the irritability is being driven by anxiety. Then we need to treat the anxiety.

RAMARIS GERMAN: Right. If we're talking about trauma related irritability, then there's some treatments, and there's evidence-based practices of it, and empirically supported treatments for the treatment of PTSD. And trauma-related disorders. So, you want to be thoughtful about sort of making sure the first step, which is to talk to your pediatrician or your healthcare provider, to assess whether the irritability is at a clinical level, and then, you know, seeking a specialist in some way who can use, you know, DSM as well as tools to identify and doing a thorough evaluation to assess where the irritability is coming from to then develop a really good effective treatment plan for your child.

RAMARIS GERMAN: I do want to highlight that irritability at a high clinical level or high level is present in about 2% to 5% of children. So again, I just want to make sure it's clear how often this occurs, and how often we see it when we do long term studies.

RAMARIS GERMAN: So, I want to shift a little bit and talk about the other part, which I'm sure a lot of you were interested in today, and what you wanted to hear about. So, I'm going to talk a little bit about what's out there in terms of treatments and interventions before I jump into the treatment that we've developed.

RAMARIS GERMAN: So, I'm going to just go through some of elements and sort of features or facets, and some theory about what's out there and how it works.

RAMARIS GERMAN: So, one piece of element, a piece about treating irritability with children, right? It's about teaching them coping skills. So, these are some examples. And again, not everything on that anger management kind of snippet is relevant. But I just took it because it was available. So, I just want to highlight that essentially teaching anger management, emotion, regulation problem solving social skills training. So, these are some examples of different elements, of helpful or useful treatments for kids, for individual children. So, psychoeducation on anger, right? Anger is adaptive and necessary.

RAMARIS GERMAN: Being angry is important, right being, and somebody's perceived injustice. When you see an injustice, you want to write the injustice, and in order to write that injustice, it is that negative feeling of anger, right negative or positive, negative feeling of anger that might motivate that behavior in terms of writing that injustice. Is the kid coming home after being bullied or being in some way, you know, said something that wasn't fair. If they saw their friend being treated in a way that wasn't fair and coming to you and saying I was angry about this, and then that's when you do something. So, I just want to make sure that it's clear that anger and irritability are adaptive. It's about the levels of presentation, and how the chat is expressing that anger. And that's what's being taught in a lot of these treatments, right? Identifying those triggers. You just gave me a ton of triggers, very thorough, and nuanced triggers at that. So that's one of the pieces. Also, where in your body do you feel it? So, they have more control, right? The lack of control with something that someone listed, teaching specific skills how to pull off, taking time out, deep breathing. You know, with a lot of the kids that I see they've gone through treatment before. These are things that they've taught. They've been taught, and the parents emphasize. Another piece is how to express yourself right, because a lot of it is sort of a miscommunication piece, sometimes not knowing how to express their anger in a way that's adaptive and helpful. So, being overly aggressive or passive, passive-aggressive, but learning how to be assertive, how to use. I statements, you know, a lot of the elements that I'm describing right now are similar to the treatments that are out there like cognitive behavioral therapy or dialectical behavior therapy for children that have been established for irritability, not for itself, but for disruptive behaviors to be clear.

RAMARIS GERMAN: So, let's talk a little bit about some foundational pieces as we move forward, which will also be relevant for the study that we've developed. So, what are some foundational pieces of theories that are effective for parents? So, we're going to move on to parents. So instrumental learning is a process through which organisms learn to perform behavior, to obtain a reward or avoid punishment. So, it's a way for them to learn behaviors. A stimulus is added or subtracted, so to reinforce means to strengthen or increase the likelihood of the behavior, or to punish, which really in this case doesn't mean punishment in the way we sometimes use punishment. But more, it's about decreasing the likelihood of the behavior and research has suggested that using positive reinforcement is the most effective way to get behavior change. So, for example, positive praise would be something like positive reinforcement. Right? You're adding something praise. And then you're trying to reinforce good behavior like great job, keeping your arms and legs to yourself. Great job! Using a lower tone of voice. Good job getting through that right? So those are all forms of positive reinforcement.

RAMARIS GERMAN: So, you know, when you go into sort of instrumental learning as a form of behavior change behavior management, one of the triggers again comes up right, because you want to know what is the child trying to communicate with behavior? Sometimes we ask, what is the function and the dysfunction?

RAMARIS GERMAN: What are they trying to communicate. What are they trying to get right? What's motivating the behavior, what's maintaining it? And that's where that reward piece like what's reinforcing, strengthening the behavior, and what's punishing, decreasing, inhibiting the behavior from being presented. For those of you who have gone through treatment before, I'm talking a little bit about antecedents, right. What happened right before? That might have led to the behavior or preceded the behavior. Behavior, the behavior itself. Right? What are they trying to say? What are they communicating with the behavior, and what are the consequences, and not in the sense that we use consequence sometimes with parents, but more the responses to the behavior action reaction kind of thing. Right? So ABCs.

RAMARIS GERMAN: I also want to talk about another theory, foundational theory of some parent management trainings, which is this course of cycle. So here we have a parent making a demand or giving a child a directive like brush your teeth. The child then refuses. Let's say they say no. The parent then threatens, brush your teeth, or else you're not going to watch your iPad today.

RAMARIS GERMAN: And then the child pushes or hits the parent. And then let's say the parent, of course, has to get to work and doesn't want to deal with it because it's a lot. So, they just kind of give up. So, in this case the child then learns that an outburst or refusing to do things will work for them.

RAMARIS GERMAN: Let's flip it to the other side, right? Sometimes. Let's say the parent same thing. Parent makes a demand. The child says, no, the parent says you're going to lose your iPad if you don't do it, and then the child then goes and brushes their teeth.

RAMARIS GERMAN: So, then the parent learns that, threatening or coercing the child works. So then, of course, what happens? So, the behavior becomes reinforced. So again, it's this bidirectional relationship between parent and child in which coercion is being used, and that's being reinforced. One of the challenges with this, and it is difficult to break, particularly, you know, children who tend to have irritability, who tend to be noncompliant, or have negative responses tend to elicit greater negative responses from their caregivers. As would be expected right, it is frustrating to have a child yelling or screaming, or saying "No," when you ask them to do something, so you yourself can get angry and then respond in that way.

RAMARIS GERMAN: So, what happens is, the behavior is reinforced in both sides. Right? So both parent and child are being reinforced for their behavior, and therefore they're more likely to engage in that behavior in the future. Obviously, escalation matters, because then it increases, how much more you threaten, how much more they threaten and how much they force. And of course, it leads to the sense of helplessness which a lot of the parents, when I see them, tend to feel that helplessness about how this course of cycle kind of maintains itself.

RAMARIS GERMAN: So, in line with that, a lot of the treatments also try to break this cycle. And that's a lot of what they're trying to do so. In doing so, they use these principles of instrumental learning. So, contingencies for rewards and punishment. Right? That's what instrumental learning is. Sort of praise. What! What kinds of things are you providing for your child to reward them or punish them for their behavior?

RAMARIS GERMAN: And again, we don't condone corporal punishment. Just to be clear. When we talk about punishments, we mean things that you do in order to decrease the likelihood inhibits likely of the behavior. So, staying consistent labeled Praise Special Time. These are some of the things obviously setting limits. And then different behavior management trainings have time out, break time, cool off time. They're all termed differently, because they all have a different goal, but they might look similar.

RAMARIS GERMAN: So, these are some of the pieces that are used in some of the behavior management training. And of course, parents, stress and emotion regulation. We talked about the coercive cycle having a child who has elevated levels of irritability is very difficult, and can be frustrating at times, I would say, to say the least. So therefore, you, attending to your own emotion, and then the child also learns through you. So, being able to manage your emotions, and then what do you communicate about anger, and how you express your anger in the system.

RAMARIS GERMAN: One last piece about some helpful aspect. Obviously, the parent child interaction is critical. So, you know, talking about increasing positive interactions, decreasing negative interactions. And then that emotional bank account so five positive interactions for every negative, so adding money to the bank, so that when you have to make a withdrawal, whether it is a demand, or give a child directive or reprimand the child. You have enough in the bank where the child is more willing to comply.

RAMARIS GERMAN: And then, making sure you know you're communicating effectively with your child, and being clear and making sure that expectations are set in a way that the child that you become predictable in that way.

RAMARIS GERMAN: So those are a little bit of my quick, brief overview of aspects and different fundamental pieces of different types of treatment, whether individual or parent management training. Now, I want to move on to our studies and what we've developed.

RAMARIS GERMAN: So, like, I said, I'm a clinical psychologist here at the Neuroscience and Novel Therapeutics Unit. What we do here is we develop treatments for children with emotional problems by studying the brain. And we try to use non-pharmacological, behaviorally based treatments to do that.

RAMARIS GERMAN: The way we study children is we look at computer tasks like attention, frustration and memory and their reaction time. We do a lot of brain imaging. So, we put children in the scanner and look at the brain mechanisms related to irritability and anger. Particularly we look at the prefrontal cortex and the amygdala, which are areas implicated in emotion regulation as well areas about attention and frustration and reward processing as well.

RAMARIS GERMAN: We also engage in digital based phenotyping. So, we use smartphones and wearables to collect data like heart rate, heart rate variability as well as assessing what people are doing in real time in their real world, right? This applies to your life in the real time at home. So, we want to know what's happening in the home, whether the treatments are effective and what's happening with the children in terms of how they're feeling during that time.

RAMARIS GERMAN: So, this is a little bit complicated, but I'm going to go through it. So, this is one of our studies I talked about theories for other treatments. I want to highlight theories for our treatment.

RAMARIS GERMAN: So, this is a translational model of irritability developed by our fearless leader, Dr. Melissa Brotman. There all the way on the far right, and Dr. Kircanski has also written about this in terms of our treatment. So, I just want to kind of highlight our basis for our exposure-based treatment just to give you a theory in case you're interested.

RAMARIS GERMAN: So the way we conceptualize irritability is that there are multiple facets. And there's essentially challenges in areas of reward, processing, and threat processing. So, what do I mean by that? So, reward processing, meaning, you know, sort of children has certain expectations about getting a reward, whether it is. Oh, you know, if you complete your homework, we'll go out for ice cream, right? And then they have strong expectation, and then, if you don't do that. They're going to have a strong reaction if they don't receive said reward, right? And then, with threat processing children with irritability, tend to see neutral faces as more sort of negative, and they also tend to focus on faces that they perceive to be threatening. So, we're looking at particularly talk a little bit about the deficits and instrumental learning like the content.

RAMARIS GERMAN: Right? So, the content of what is within that instrumental learning. So, the contingencies for the behavior. So, what the parent provides, whether it's praise, what kinds of rewards they give things like that. And then there's also, in terms of their process, they have deficits in instrumental learning. So, when to expect rewards, and how to adjust their behavior when those contingency change right? If something changes, if you no longer giving a treat, let's say, for homework completion. They're going to have a strong reaction to that. So this is sort of my way of trying to explain this model, and what we think is that they have a lower threshold right? Which then leads to these challenges for these children. And then the response is increased. Motor activity and aggression. Right? What is that? Well, that's that behavioral piece. That's that temper outburst. And then anger increased anger and frustration. Right? Which is that mood component.

RAMARIS GERMAN: So, what we're trying to do is we develop treatment that tries to target these areas that we think that have been challenging for our kids with DMDD that have or that have that level of irritability.

RAMARIS GERMAN: So, what we proposed was to expose children to threat and frustration while tolerating their anger to normalize those areas, that processing of reward, that processing of threat? So that they decrease their anger and frustration.

RAMARIS GERMAN: So, why exposure? So, we think we know that exposure works in anxiety and anxiety and irritability are very similar in terms of their responses, so they both have to do with responses to threat. Right? So, when they have a perceived threat, so think of fight, flight, or freeze. So instead of flighting right, it seems like children with irritability, tend to go towards approach or fight, and then like anxiety. Right? They're both kind of short term. They both start somewhere, and then high arousal state, meaning it evokes energy, evokes energy, or in the system. So, something happens. The child becomes irritable or anger, it comes up, and then it goes down. So, the same thing, right? If a child is anxious about an upcoming exam, let's say, or presentation, and then the presentation happens. They got to go up right, and then the anxiety comes back down.

RAMARIS GERMAN: So, we think that they're both very similar, and that's what we think exposure. So, being able to expose the children to the anger, inducing stimuli while tolerating the anger without engaging in these responses, will help them.

RAMARIS GERMAN: And then, of course, we want to also tackle the instrumental learning component. And we do that through parent management training. So, addressing sort of how we praise, how we reward sort of the reward contingencies for the children in terms of their behavior, and then sort of what? To set expectations in a way that are more predictable for children.

RAMARIS GERMAN: So, let's go into what is exposure therapy. I'm sure some of you are familiar, particularly mental health providers here. So, it's a thing that involves changing one's behavior to treat fear and anxiety and involves areas of the brain related to attention and emotion, regulation like the amygdala and the prefrontal cortex.

RAMARIS GERMAN: So, patients are repeatedly exposed to a feared object or stimuli, and we create a fear hierarchy. So, a list of objects that tend to induce fear in the child or anxiety. So, what we do is we create what's called a SUDs, a subjective unit of distress. And then we identify levels at which the child would feel anxiety at different levels. So, let's say, seeing a picture of a spider, might induce less anxiety as opposed to seeing a spider through a glass as opposed to touching a spider, and of course this would probably also be an exposure, for most of us would induce a lot more fear. So, the idea is that we move up. Then the child is able to see a spider and sort of not engage in the avoidance behavior that they used to. So, in the past, let's say, a child who has this fear or fear of bugs might not go out, let's say, because they're afraid they might see a spider, but being able to help them approach the spider over time, will mute the response of anxiety, and ultimately allow them to thrive and continue to live their lives despite them being spiders out there.

RAMARIS GERMAN: So, we think that trying to translate exposure for anxiety to irritability would work for addressing those pieces in that translational model. So, instead of hierarchy of fear inducing stimuli to anxiety, say the spiders or the black, we would do a hierarchy of anger, inducing stimuli for irritability, and I have to say, for the person who said, folding laundry. Very good.

RAMARIS GERMAN: Good job. So here it is. Yeah. Folding laundry, you know. It's 7 to 5, 7, but 5 to 7 business days to fold it. It takes. It's frustrating to most. And some of our kids definitely throw temper outburst, having to do that. So that would be irritability, inducing stimuli instead of changing the avoid strategy right in anxiety, we would change the approach strategy in irritability, like aggressing or temper outbursts.

RAMARIS GERMAN: So, what are some common components? I do want to be clear that this is not intended for those with a trauma history, and that there are obviously treatments out there for individuals who do have irritability as a result, let's say, of trauma, or some form of trauma related disorder, such as PTSD. So, this is more for children who have irritability as that sort of similar to the one that I've described in DMDD.

RAMARIS GERMAN: So, we do motivational interview. We took that from some of the substance. Use literature to try to get the child on board right, get them bought in. It's usually the parent who's seeking treatment, not the child. The child's kind of like huh. So, we want to make sure that they're here because they want to be here, and we identify target treatment targets and acknowledging. Again, the anger is helpful and sort of what's causing the problems. And we try to tackle the problems of anger, not anger in and of itself per se.

RAMARIS GERMAN: We talk about the same things we talked about earlier in terms of where do you fear, anger? What does your anger look like? And then the critical piece is this exposure component, right? The hierarchy in session, exposure to try to inhibit those maladaptive approach responses, everything that you listed in terms of those temper outbursts as well as inhibitory control, teaching our children to inhibit their response, to try being aggressive or yell or scream. And then we have parent sessions that are focused on learning theory like I talked about before, so rewarding, positive, being consistent, being predictable in that way, praise, active, ignore, setting limits and providing effective commands.

RAMARIS GERMAN: So this was covered in a Wall Street Journal article. And there was a description about this particular kid with folding laundry. So, I'll walk you through that.

RAMARIS GERMAN: So essentially what we did - we developed the anger hierarchy for this child, and we started with sort of just looking at the laundry, and then ultimately starting to sort the laundry and then folding the laundry and we extended this to other children, let's say, brushing their teeth, having to do hard homework or stop playing video games which is really challenging.

RAMARIS GERMAN: So how does this look like in session? Essentially, we prepare the child for the exposure child predicts from one to 10 - how angry they're going to get. We ask them for a baseline rating, and then we engage in the exposure, whatever it is, whether it's we have them brush their teeth. Sometimes we'll play a two on one basketball game, so they get used to losing, or we'll rig the game. So, these are some of the things we do in order to expose the child to those anger inducing stimuli. And it's very specific for the child after we created this list of anger, inducing events or situations that are specific to that child. This is an example from an actual child, so, as you can see, anger goes up and comes down right. This is what I was telling you about acute in this way, and eventually over time those peaks become lower and lower and lower, and the child gets used to either. The event which then translates to other things, whether it's chores at home, or having to do laundry, or whatever else it is.

RAMARIS GERMAN: So, I want to give a shout out to the wonderful clinical team and all their hard work to help us identify whether this works and providing the treatment. So, let's look a little bit about what this looks like. So, I want to make sure we are clear about who the sample is. Right. Now, in terms of this particular sample, I'm going to be talking about. We completed it with 40 youth predominantly. Children with DMDD.

RAMARIS GERMAN: Mostly males about 11.2 3 years old, and of course we are currently working in terms of trying to change our diversity data in terms of getting more individuals from diverse cultures. But currently, it's predominantly white in terms of the sample.

RAMARIS GERMAN: So how does it work. We had a multiple baseline design because we wanted to provide the treatment to everyone. Since it is a new treatment. We had kids do have a baseline period in which they we were just following them without any treatment, and, as you can see here, according to clinician, rated irritability, and the clinician didn't know when the child started the treatment because we had children start treatment at two, four, or six weeks.

RAMARIS GERMAN: There were no significant changes. However, during the treatment period when the exposures and parent management training was provided, the child did decrease their irritability significantly, and what we see here is that those changes were maintained. So, the children did stay better over time and didn't go back to pre-baseline levels.

RAMARIS GERMAN: So, what can we say about the treatment? Right? Firstly, we showed that exposure could work for irritability. So, we identified a procedure that works for that. We also show that children do tend to change their approach of behavior. So, temper, outburst, decrease as well as their irritable mood.

RAMARIS GERMAN: Some limitations are that we don't have a comparison group. So, everybody knew they were getting the treatment so that kind of creates a challenge because we don't know if it's just getting treatment that makes them better? Or is it something unique about what we hypothesized, particularly exposures, that caused this change or led to this change.

RAMARIS GERMAN: And then families knew they were getting the treatment. So can they have these beliefs or expectations. And we don't know how it works. So, here's some future ideas that we have about how to test how it works. And we're currently looking at how areas of the brain are involved in emotion, regulation, and attention like that prefrontal cortex and amygdala areas that we talked about. We're also looking at signs of change during the exposure. So now, children wear a watch that assesses it's not really a watch but assesses their heart rate and heart rate variability.

RAMARIS GERMAN: And, like I said before, we have children go out in the real world with phones, and the parents to identify what irritability outbursts and those behaviors look like in real time, as well as assessing parents use of the interventions in in terms of their real day to day life.

RAMARIS GERMAN: So, I do want to provide you with some resources. I'll give you some time to QR code. These are some possible resources for you to look at. If you have more questions, or it sounds like, maybe I do know a kid like this. Maybe this is my child. These are places that you can go to, possibly to learn more.

RAMARIS GERMAN: And well, I listed a couple of books that are also resources, particularly the middle one. If you have been through what's called parent child interaction training, this is the book that they have a companion book for parents, as well as some other books that are available out there for children who have these types of disruptive behaviors that might be similar.

RAMARIS GERMAN: And also, they're being added to the chat. So, if you just want to click on the link in the chat. You can just click on that. And hopefully they stay open for you, and you're able to. Get that.

RAMARIS GERMAN: Well, I would say, thank you to all our patients and families, primarily, because without their devoted time and altruistic behavior, we would not be able to do any of this work and present it to you, so we're very grateful to them, as well as all the individuals here, you know, particularly Dr. Brotman, who is the leader of our lab, Danny Pine, Collins, Jamell, Lisa, all of these individuals. Kalene. Thank you so so much. She's there in the background doing the work. She's the one sending you this, so thank you as well as all the other staff that we have, and I couldn't put everyone's name here. I wish I could, but I want to say thank you to everyone, for all the work that we can do.

RAMARIS GERMAN: And I want to say, thank you to you for coming today. I really appreciate you coming and listening to us. We are recruiting for that study that I just talked about. I do want to highlight and emphasize that we are looking for individuals who are within a 50-mile radius of NIH. Particularly we are in the Bethesda campus, so 50-mile radius from the Bethesda campus here. That's where I'm talking to you from today. And of course, just to be clear, there's forms of eligibility, and some would be exclusionary. So just click on that, and you can get started with our process if you're interested.

RAMARIS GERMAN: So, thank you.

NIMH SUPPORT: Dr. German, I'll go ahead and just type those into the chat for you.

RAMARIS GERMAN: Great. Thank you.

RAMARIS GERMAN: Oh, that's a great question.

RAMARIS GERMAN: So essentially, one of the keys, critical pieces and differences is going to be that mood component for sure. In terms of one of the questions, what a difference between oppositional Defiant disorder and DMDD. Is that what they're asking for? Do you think that's the question.

NIMH SUPPORT: Yes. Correct.

RAMARIS GERMAN: Okay, okay, so yeah, so essentially, one of the key differences is going to be that mood component with DMDD, particularly that 51% of the time the child tends to be irritable. There is a large debate around what would ultimately you know whether there's a difference in terms of the DMDD diagnosis and the old diagnosis. But when you think about the criteria you think about these two components, particularly the two domains that I talked about I would say that mood piece is going to be critical. There are serious, large overlaps between the two in terms of ODD. And obviously with oppositional defiant disorder. If a child does have DMDD, then they do not get an oppositional defiant disorder diagnosis, because DMDD subsume ODD, according to the DSM.

RAMARIS GERMAN: Both temper outbursts can look very similar. And of course there's obviously some other pieces about the diagnosis.

RAMARIS GERMAN: So DMDD is exclusively reserved for children or youth. So, one of the critical pieces of the diagnosis is that it has to be present prior to age 10, and then after age 6. So, I would say DMDD would not be a diagnosis given in an adult per say.

RAMARIS GERMAN: So, I think, assessing how long the irritability has been, for remember, it has to be at least a year, so I would. I would venture to try to identify the root of the of the irritability, and where these anger management issues are coming from, and whether there's other components there right in terms of. And I understand that here it says they don't meet criteria for anxiety, bipolar, depression. So, and I think that's what's complicated sometimes about DMDD sort of putting people in those buckets, and particularly the demarcation that the DMDD provides with the, you know, criteria sometimes don't fit quite neatly in the patients that we end up seeing. So, finding sort of what looks like a good treatment for I mean a good diagnosis for this person when I say treatment, because the diagnosis will inform the treatment right? What treatment you provide and sort of what your treatment plan looks like. So that would be my best way of answering that.

RAMARIS GERMAN: Great question, how do ADHD and DMDD intersect? So, there is a huge overlap, and I will be transparent, that I would say at least 80% of our children do have ADHD. So, I would say that in that sense that there is, they can be comorbid.

RAMARIS GERMAN: And then, you know, with ADHD, there's a lot of other pieces in terms of the inattention, the hyperactivity, as well as sort of those challenges that can be present that may not necessarily be present in DMDD, so I think it's really identifying triggers for the irritability. So, what are the triggers. I think that's usually where I start and then that can help me sort of have a better diagnostic picture. So, I take a really look. So, walk me through your week, and when was the last time your child? So, I would take? I would try to go through at least certain outbursts like, is it a specific time? Is it doing homework? Is it at school? What are the demands in the situation? Particularly when it comes to children with ADHD? Are they being asked to sit still? Are they being asked to pay attention? What is the kind of pieces that are the factors that are at play right now that would lead this person or this child to be irritable, or express anger, or have a temporal person this way compared to children with DMDD, so I would say that those are some of the components. Also, that mood component is critical right? Because DMDD are part of the mood disorders. So how often is the child irritable? And what is their baseline mood? I usually start there. And what would you say is, you know again, that pie? What percent of the time do they spend being angry or irritable versus other? And then, of course, triggers and what that looks like.

RAMARIS GERMAN: So yeah, it's interesting because I didn't put intermittent explosive disorder in there. I said, there's about 20 DSM disorders that could have it so intermittent explosive disorder when I think about it, I think about it differently. I think about yes, the temper out versus there, I think about reactive aggression versus proactive aggression, sometimes, right? So, one piece about DMDD is that most our kids who would get diagnosed with DMDD, they have reactive aggression. So usually, it's in relation to some form of incident that happened. Remember, something happened, and then they get angry, and then they express it for the most part. So, I would say in general, I tend to think about that as a differentiating component.

RAMARIS GERMAN: As well as you know, sort of these other criteria, as it relates to DMDD like, what would the trigger? How long has it been? What starts it? And then where are they being reactive, or are they proactively arresting somebody, you know. Is there no incident, or something that happened? Was they being not that led to that as well as the other pieces related to what's in the DSM themselves about those disorders?

RAMARIS GERMAN: Oh, look at the time! So, thank you. Everyone for coming. I can't see you, but thank you again, for being here, I'm very grateful to have been had the opportunity to share this with you. I hope you find it helpful. And yeah, please stay tuned for the next one of these, which will be in a couple of months or so. Thank you.

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