Emotion Dysregulation in Children and Adolescents: Part II

      Part I of this special issue describes the many psychiatric disorders in which explosive outbursts may play an important role. Bipolar disorder, disruptive mood dysregulation disorder, oppositional defiant disorder, posttraumatic stress disorder, or mixtures of diagnoses like co-occurring attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, or autism spectrum disorder are the conditions we describe with case examples. As we noted in Part I, none of these diagnoses are synonymous with or consistently describe the behavior itself. We, in fact, lack a consistent definition of outbursts, and so we lack an outcome measure to identify their severity, duration, and frequency. This complicates our ability to design and conduct clinical trials, which, in the absence of a clinically meaningful outcome measure, may be destined to fail. At this time, youth with outbursts are frequently exposed to multiple psychotropic medications with limited information as to their long-term impact. Nevertheless, medications combined with a collaborative system of care and using a developmental lens can be a blessing if they decrease the risk of escalation and the significant multi-domain impairment that ensues if the problem is untreated. Thoughtful treatment, however, is a challenge especially in globally under-resourced treatment settings.
      Whereas Part I focused on psychopathology and treatments of specific conditions, the second part critically evaluates the benefits of existing psychosocial and pharmacologic interventions and makes recommendations for how these interventions can evolve with an improved understanding of behaviors underlying emotion dysregulation, the etiologic factors that contribute to perpetuating the dysregulation, and the various settings in which the dysregulation occurs. We aim to approximate which treatments fit well for which youth, with an exploration of the timing of the interventions along primary, secondary, and tertiary prevention. Thus, a developmentally informed lens focuses on clinically meaningful outcomes and knowing when and in what setting to inform patients and families to seek care.
      The first 2 articles introduce the concept that development matters. The first paper by Dr Crowell is a review of normative development of emotion regulation. The second, by Dr Kessel and colleagues, uses multiple methods and informants in a prospective longitudinal design to demonstrate the antecedents and continuity of irritability from early childhood to adolescence. The next series of articles review the extant literature for existing interventions across multiple settings. The first of these articles by Dr Bostic and colleagues characterizes outbursts in a school setting and makes recommendations for interventions that address behavioral, emotional, impulsive, and sensory components across the stages in the evolution of explosive outbursts. The second of the series on interventions across settings is by Dr Chua and colleagues, and reviews the limited extant literature on behaviors that require seclusion or restraint in inpatient settings. The third article by Dr Huefner and colleagues uses data to inform decisions about the timing, objectives, strategies, and contexts best suited to reduce seclusion and restraint in preadolescents in a residential treatment center.
      The next two articles review extant pharmacological strategies for explosive and aggressive behavior, first across broad diagnostic groups, by Vaudreuil and colleagues, and second, in bipolar disorders, by Drs Patino and DelBello. We follow these with 4 articles that review psychosocial and preventive interventions for emotion dysregulation, first with a comprehensive review by Dr Waxmonsky and colleagues of a wide range of evidence-supported effective psychosocial interventions, followed by a review by Dr Singh and colleagues of strategies that both prevent onset or progression of emotion dysregulation and build resilience. We have learned that family support is critical to intervening on emotion dysregulation in youth, so additional attention by Dr Salem and colleagues was paid by to the long-term beneficial role of family psychoeducation and skill building in reducing rage, mood symptom severity, disruptive behavior, and associated executive functioning deficits that commonly cooccur. We conclude this series of articles with a modular approach by Drs Evans and Santucci to provide flexible and personalized matches for psychosocial treatment components based on specific clinical presentations.
      In the final 2 articles Dr Burke and colleagues first consider the long-term course and outcome of chronic irritability and oppositional behavior, and Dr Dickstein and colleagues review the application of neuroscience tools to evolve mechanistically rooted interventions that target brain-based origins of emotion dysregulation. At the conclusion of this issue, Drs Leibenluft and Kircanski provide a reprise to both parts of this special issue.