An Exposure-Based Cognitive–Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

ABSTRACT

Objective

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

Method

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive–behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

Results

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > –0.04, ps < .011, Cohen’s d range: –0.33 to –0.98). Treatment gains were maintained at follow-up (all βs₍₃₉₎< –0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

Conclusions

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

Acknowledgments

The authors appreciate the roles of Drs Ellen Leibenluft, Daniel S. Pine, and Wendy Silverman in consultation and discussion about the study design, protocol, and findings. The authors would like to thank Drs Lisa M. Cullins, Jamell White, Miryam Kiderman, and Cheri McNeil, as well as to Ms Lisa Felber, Wanda Wheeler and Mollie Davis, the therapists and clinical raters of this study, for their dedicated work. The authors would also like to thank the patients and families for their time and participation.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplementary data

Supplemental material for this article can be accessed online at https://doi.org/10.1080/15374416.2023.2264385

Additional information

Funding

This work was supported by the Intramural Research Program (IRP) of the National Institute of Mental Health, National Institutes of Health [ZIAMH002786-15, ZIAMH002778-17], and conducted under NIH Clinical Study Protocols 02-M-0021 and 15-M-0182 [ClinicalTrials.gov identifier: NCT02531893 (Brotman)]. This body had no role in the study design, writing the manuscript, or the decision to submit the paper for publication. This research received no specific external grant from any funding agency, commercial or not-for-profit sectors.