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

Figures & data

Figure 1. CONSORT diagram.

Table 1. Participant demographic information.

Age (Mean, SD)	11.23 (1.85)
Sex (n, %)	Male (25, 62.5)
	Female (15, 37.5%)
Any Medication (n, %)^a	30, 75
Stimulant (n, %)	20, 50
Non-stimulant ADHD medication (n, %)	12, 30
Antidepressant (n, %)	14, 35
Antipsychotic (n, %)	3, 7.5
Anticonvulsant (n, %)	1, 2.5
Telehealth completers (n, %)	21, 52.5
Race (n, %)	White (31, 77.5)
	Black or African American (4, 10)
	Asian (1, 2.5)
	Multiple Races (3, 7.5)
	Unknown (1, 2.5)
Ethnicity (n, %)	Not Latino or Hispanic (36, 90%)
	Hispanic or Latino (2, 5)
	Unknown (2, 5)
Primary Diagnosis^b (n, %)	DMDD (25, 62.5)
	ODD (10, 25)
	ADHD (5, 12.5)
IQ (Mean, SD)	113.43 (13.70)
Parent Income	Over $180,000 (13, 32.5%)
	$90,000–$179,999 (9, 22.5%)
	$60,000–$89,999 (1, 2.5%)
	Unknown (17, 42.5%)
Child Opportunity Index (COI)^c
Education (Mean, SD, Level)	84.31 (10.07), Very High
Health & Environment (Mean, SD, Level)	71.63 (22.88), High
Social & Economic (Mean, SD, Level)	88.40 (12.97), Very High
Overall COI (Mean, SD, Level)	87.31 (13.01), Very High

Note: DMDD = disruptive mood dysregulation disorder; ADHD = attention deficit hyperactivity disorder; ODD = oppositional defiant disorder. IQ was not assessed for n = 12 telehealth completers.

^aParticipants may be prescribed more than one medication type (n = 14 prescribed one type; n = 12 prescribed two types; n = 4 prescribed three types).

^bBased on DSM-5 guidelines, the DMDD diagnosis supersedes an ODD diagnosis. Therefore, children with both DMDD and ODD were given a primary diagnosis of DMDD.

^cThe Child Opportunity Index (Noelke et al., 2020) is a composite metric of the neighborhood conditions/environment of children that accounts for education, health, social, and economic factors of specific neighborhoods as compared to national averages. The COI reflects U.S. nationally normed scores on a scale of 0–100; COI data were available for n = 35 participants.

Table 2. Participant comorbidities by primary diagnosis.

Diagnoses	Diagnostic Group
	DMDD (N = 25)	ODD (N = 10)	ADHD (N = 5)
ADHD	20 (80%)	5 (50%)	–
Separation anxiety	4 (16%)	3 (30%)	1 (20%)
Generalized anxiety	13 (52%)	2 (20%)	1 (20%)
Specific phobia	4 (16%)	0	0
Social phobia	1 (4%)	0	1 (20%)
Tic disorder	1 (4%)	0	0
Enuresis	1 (4%)	0	2 (40%)
Chronic motor disorder	2 (8%)	0	0
Excoriation disorder	1 (4%)	0	0

Note: DMDD = disruptive mood dysregulation disorder; ADHD = attention deficit hyperactivity disorder; ODD = oppositional defiant disorder.

Table 3. Clinical outcomes: clinician- and self-reported irritability, anxiety, depression, ADHD, and global functioning across treatment and follow-up timepoints.

Outcome measure Mean (SD)	Pretreatment^a N = 40	Mid-Treatment N = 40	Post-Treatment N = 40	3-month follow-up N = 36	6-month follow-up N = 35
Clinician ARI Total Score	43.63 (17.43)	39.31 (16.08)	36.11 (19.94)	33.58 (20.59)	31.59 (20.96)
CGI-S Temper Outbursts	4.18 (.81)	3.65 (.864)	3.33 (1.05)	3.17 (1.28)	3.09 (1.36)
CGI-S Mood	3.28 (1.28)	3.08 (1.12)	2.77 (1.25)	2.61 (1.25)	2.60 (1.24)
CGI-S DMDD Severity	4.05 (.85)	3.65 (.80)	3.35 (1.05)	3.08 (1.25)	2.97 (1.29)
Parent ARI	7.12 (2.73)	5.88 (2.55)	4.82 (3.03)	–	–
Child ARI	4.72 (3.70)	4.53 (3.28)	3.9 (3.36)	–	–
Clinician-rated anxiety (PARS)	5.78 (4.93)	5.12 (4.53)	5.20 (4.80)	3.82 (3.57)	5.20 (4.07)
Clinician-rated depression (CDRS)	25.70 (5.32)	24.65 (4.60)	25.13 (8.11)	23.15 (4.76)	24.69 (7.34)
Clinician-rated ADHD (ADHD-RS)	21.30 (14.16)	22.13 (12.70)	21.90 (13.99)	23.12 (12.97)	21.51 (14.50)
Children’s Global Assessment Scale (CGAS)	49.38 (8.21)	50.87 (6.77)	53.85 (9.52)	56.53 (12.28)	57.26 (13.36)
Parent SCARED	19.58 (11.55)	18.53 (13.25)	16.97 (12.21)	–	–
Child SCARED	19.45 (18.80)	18.11 (16.47)	17.56 (18.04)	–	–
Parent SMFQ	6.23 (3.70)	5.80 (3.52)	5.03 (3.89)	–	–
Child SMFQ	5.70 (5.92)	4.28 (4.79)	5.33 (5.53)	–	–
Parent CPRS-R (DSM IV t-score)	70.21 (12.32)	67.67 (11.40)	67.72 (11.94)	–	–

Note: ARI = Affective Reactivity Scale; CGI-S = Clinical Global Impressions-Severity, PARS = Pediatric Anxiety Rating Scale; CDRS = Children’s Depression Rating Scale; ADHD-RS = Attention-Deficit/Hyperactivity Disorder Rating Scale; SCARED = Screen for Child Anxiety-Related Disorders; SMFQ = Short Mood and Feelings Questionnaire; CPRS-R = Conners’ Parent Rating Scale-Revised.

3-month follow-up assessment completed by n = 36 participants; 6-month follow-up assessment completed by n = 35 participants.

^aPretreatment assessment was the last clinical assessment of the baseline phase occurred before the start of treatment.

Table 4. Clinical outcomes: improvement in temper outbursts, irritable mood, and DMDD severity as measured by CGI-I.

CGI-I Temper Outbursts (N = 40) Mean (SD)
Pre vs. Mid	4.18 (1.01)
Pre vs. Post	3.82 (1.15)
Pre vs. 3-month follow-up	3.69 (1.37)
Pre vs. 6-month follow-up	3.69 (1.64)
Mid vs. Post	4.28 (1.11)
CGI-I Mood
Pre vs. Mid	4.56 (1.17)
Pre vs. Post	4.08 (1.16)
Pre vs. 3-month follow-up	3.97 (1.59)
Pre vs. 6-month follow-up	3.89 (1.66)
Mid vs. Post	4.34 (1.26)
CGI-I DMDD Severity
Pre vs. Mid	4.36 (.93)
Pre vs. Post	3.98 (1.31)
Pre vs. 3-month follow-up	3.86 (1.55)
Pre vs. 6-month follow-up	3.71 (1.55)
Mid vs. Post	4.34 (1.66)

Note: CGI-I = Clinical Global Impressions-Improvement. 3-month follow-up assessment completed by n = 36 participants; 6-month follow-up assessment completed by n = 35 participants. Pretreatment assessment was the last clinical assessment of the baseline phase occurred before the start of treatment.

Figure 2. Clinician-rated irritability change across study phases as measured by CL-ARI and CGI-S.

Abbreviations: CGI-S = Clinical Global Impressions-Severity; CL-ARI = Clinician Affective Reactivity Scale. x = 0 represents pretreatment assessment. Dashed gray line represents mean participant length in treatment = 14.1 weeks (SD = 1.9 weeks); one participant took 23 weeks to complete all treatment sessions. Shaded gray regions represent standard error (SE).

Noelke, C., McArdle, N., Baek, M., Huntington, N., Huber, R., Hardy, E., & Acevedo-Garcia, D. (2020). Child opportunity index 2.0 technical documentation. https://diversitydatakids.org/researchlibrary/research-brief/how-we-built-it

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