Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them.

OBJECTIVE: Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD: The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS: Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION: Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Tools to Craft a Cultural Formulation.

Clinicians should strive to understand every patient from their own perspective. The authors present tools to help patients narrate their own experiences and elaborate on the context of their symptoms, allowing clinicians to appreciate the cultural influences on a patient and how that affects their symptomatology. This knowledge can then be crafted into a nuanced cultural formulation of the patient, with the goals of not only better understanding the patient's specific, intersectional context but also guiding treatment planning. As a result, the patient is evaluated in a holistic manner, and their specific needs are central in their care.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents.

PURPOSE OF REVIEW: Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice. RECENT FINDINGS: There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

Of Triggers, Tigers, and Tactics: Managing Emotional Dysregulation.

The frustration of defining, understanding, and addressing irritability in child psychiatry and the difficulties that children with emotion dysregulation face on a daily basis can be seen as parallel processes. We know that irritability is one of the most common reasons for which children are referred for evaluation.1 We also know that the stakes are extremely high, with persistent irritability associated with suicidality.2 Despite this, we do not have a readily available nosological paradigm. Our current clinical approach remains muddled by outbursts' transdiagnostic nature. We find ourselves listing things such as posttraumatic stress disorder, disruptive mood dysregulation disorder, attention-deficit/hyperactivity disorder, anxiety, and depressive disorders in the chart, but feeling that we have not fully captured the unique neurobiological and subjective essence of a child's irritability syndrome.3 Furthermore, despite extensive research, we lack accessible diagnostic tools or effective treatment protocols to implement on a community-wide basis. So, we (JC, CU) think we have every right to be irritable as we experience frustrative non-reward (thinking and focusing on this issue with blocked goal attainment) and face existential threat (desperately wanting children and families to enjoy better developmental trajectories, and wanting it now!).4.

Treatment of Childhood Emotion Dysregulation in Inpatient and Residential Settings.

Children hospitalized in inpatient and residential treatment facilities often present with severe emotion dysregulation, which is the result of a wide range of psychiatric diagnoses. Emotion dysregulation is not a diagnosis but is a common but inconsistently described set of symptoms and behaviors. With no agreed upon way of measuring emotion dysregulation, the authors summarize the existing contemporary treatment focusing on proxy measures of emotion dysregulation in inpatient and residential settings. Interventions are summarized and categorized into individual- and systems-level interventions in addressing aggressive behaviors. Going forward, dysregulation will need to be operationalized in a standard way.

Dr. Carlson et al. Reply.

We appreciate the thoughtful and supportive comments from Dr. Masters1 and agree that coercive parent-child relationships were often what was addressed and modified during hospitalization. Lowering seclusion and restraint rates by prohibiting them, without lowering rates of aggression, is not the desired outcome. As we noted in our paper, evidence-based treatments are sorely needed for young children whose severe and destructive outbursts get them psychiatrically hospitalized.

Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study.

OBJECTIVE: There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued. METHOD: We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use. RESULTS: Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002). CONCLUSION: In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.