Abstract
Objective
As part of the 2019-2021 presidential term of the American Academy of Child and Adolescent Psychiatry (AACAP), the AACAP Presidential Initiative on Emotion Dysregulation in Youth Taskforce was established. The aim was to address emotion dysregulation in children and adolescents, focusing on developing methods for clinicians to identify, characterize, and treat impairing emotional outbursts along with development of a research agenda that would guide relevant researchers and research funders. One method to characterize emotion dysregulation was accomplished by recommendations for use of a diagnostic code that is available in the DSM. The research agenda is presented here.
Method
The Taskforce specifically focused on aggressive behaviors and emotions associated with outbursts. The development of a research agenda took place over 2 years of examination of the current needs in the literature, with contributions from experts in the field. This work dovetailed with the efforts from the Congress on Pediatric Irritability and Dysregulation, which had been meeting since 2015 to advance research into the measurement, pathophysiology, and treatment of emotion regulation problems in youth. We concentrated on the central questions concerning the measurement of outbursts, key questions linking outbursts to other psychopathologies, and how behavior in outbursts is separable from typical behavior.
Results
A description of the qualitative data gathering process is provided here, along with the following: recommendations in the research areas of measurement; pathophysiology; delineating outbursts from other psychopathologies; exploring the cultural, social, and interpersonal aspects of outbursts; understanding the prevention and treatment of outbursts; and exploring how outbursts manifest and are treated based on setting. Specific examples of research opportunities and future directions are provided.
Conclusion
A call is made to funding agencies to examine the spaces within their strategic plans that will allow for engagement in critical efforts to improve the lives of children and adolescents with severe emotional outbursts—some of the most impaired individuals presenting for care in child and adolescent psychiatry.
Key words: irritability, outbursts, emotion regulation, research, RDoC
Plain language summary
The 2019 to 2021 AACAP Presidential Initiative on Emotion Regulation in Youth Taskforce was created by Dr. Gabrielle A. Carlson and aimed to address the field of treatment and research of youth with impairing emotional outbursts. The taskforce was made up of clinicians and researchers, including experts from the Congress on Pediatric Irritability and Dysregulation, and focused on developing methods for clinicians to identify, characterize, and treat impairing emotional outbursts. The 2-year taskforce led to the development of a research agenda to guide next steps for researchers and research funders. Diverse input from junior and senior investigators, clinical psychologists, graduate, and post-graduate students was encouraged. This report details the qualitative data gathering process and recommendations for the field.
Impairing emotional outbursts continue to be a primary reason for emergency department visits and hospitalization among youth.1,2 The impact of these outbursts is felt by youth, their families, and the healthcare team, but research into the cause and treatment of outbursts occur remains relatively nascent.3 As part of the 2019-2021 presidential initiative for the American Academy of Child and Adolescent Psychiatry (AACAP), the AACAP Presidential Initiative on Emotion Dysregulation in Youth Taskforce (authors of this manuscript) was established to address emotion dysregulation in children and adolescents; focusing on developing methods for clinicians to identify, characterize, and treat impairing emotional outbursts. In addition, the Taskforce was charged with the development of a research agenda that would guide the field. The following research agenda builds directly on the narrative review of the Taskforce, published in 2023.3
There have been entire volumes written about facets of emotional regulation, emotional dysregulation, self-regulation, and irritability.4, 5, 6 For the purposes of this Taskforce and research agenda, we specifically focused on the emotional and behavioral symptoms of outbursts—which have also been called “temper outbursts,” “affective storms,” “severe irritable mood,” “rage attacks,” “severe mood dysregulation,” and “tantrums,” among others,7 to inform advancement in measurement and subsequent treatment. Throughout this report, we are focused on the discussion that occurred on the research and treatment of emotion regulation problems and irritability, and subsequent measurement and research related to outbursts. This research agenda examined the current unmet clinical needs as reflected in the literature and reported by experts in the field. This work dovetailed with the work from the Congress on Pediatric Irritability and Dysregulation (CPID; see attendees from previous meetings at: http://www.childemotionregulationlab.org/congress-on-pediatric-irritability-and-dysregulation.html), which has been meeting since 2015 to advance research into the measurement, pathophysiology, and treatment of emotion regulation problems for youth. The work of the Taskforce centered around the following questions:
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How might research on outbursts contribute to our understanding of irritability and emotion dysregulation?
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There are many measures of emotion (dys)regulation and aggression and some of irritability. Are there good measures of outbursts? If not, what do we need?
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What are the key outstanding research questions involving emotion dysregulation and irritability right now?
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How do outbursts, emotion dysregulation, and irritability change with development, and how do we conceptualize and measure what is age-appropriate behavior and mark the boundaries between typical and atypical behaviors?
The combination of the research interests at CPID with the clinical, educational, and research areas being considered by the AACAP taskforce3 proceeded through a qualitative data gathering process and generated a series of questions that remain to be answered and studied. The Taskforce modified and developed these questions further into a draft research agenda, which again was shared with the clinical and basic science researchers at CPID. Over the course of the congress, questions were further modified, and research areas were identified and discussed via general group discussion and smaller breakout discussions. Together, therefore, the questions presented in Table 18-10 comprise the collective opinions of more than 170 clinicians and researchers about the role of outbursts in youth. Research questions were categorized under general topics, including specificity to particular settings.
Table 1.
Research Questions That Arose From the American Academy of Child and Adolescent Psychiatry Presidential Taskforce on Emotion Dysregulation and the Congress on Pediatric Irritability and Dysregulation Meetings
| Topic area | Questions |
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| General | How do we develop a common language for characterizing outbursts? |
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| How do we measure outbursts? | |
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| What kinds of outcomes are important? | |
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| Where are the boundaries between outbursts and other constructs? | |
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| How do we incorporate issues of diversity, equity, and inclusion?a,b | |
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| What do we know about the pathophysiology of outbursts? | |
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| What questions remain about prevention and treatments for outbursts? | |
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| Related to specific settings | |
| School | |
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| Home | |
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| Emergency department | |
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| Psychiatric inpatient/residential | |
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| Outpatient | |
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Note: ADHD = attention-deficit/hyperactivity disorder; ASD = autism spectrum disorder; DMDD = disruptive mood dysregulation disorder; IED = intermittent explosive disorder; ODD = oppositional defiant disorder; PRN(s) = pro re nata medication(s); PTSD = post-traumatic stress disorder.
OSF Preregistration: Cross-Cultural Examination of Irritability and Associated Symptoms: Findings and Inferences. https://doi.org/10.17605/OSF.IO/GW7JB
OSF Preregistration: Measurement Invariance of the Affective Reactivity Index Across Various Countries. https://osf.io/d2zfp/
A series of underlying themes emerged from this stepwise review of salient research topics. Overall, the groups were clear that there is no commonly used, current measure universally agreed upon in the field to measure all relevant aspects of outbursts. There was also agreement that a major research gap remains to focus on the measurement of outbursts, and then to determine the relations between measurement and other components of emotion dysregulation. From there, subsequent data about the context of outbursts within specific psychopathologies and in other settings can be examined.
Based on these questions, comments, and ensuing discussion, the Taskforce specifically concerned itself with creating clear, measurable, and achievable research goals that, with the appropriate energy and resources, could be addressed in the relative near term (1-5 years). Taken overall, the Taskforce recommends methodological advancements in research on emotion dysregulation and irritability across the 6 domains discussed below.
Measurement of Outbursts
There is a need for a consistent and well-accepted measure(s) of outbursts to be used in conjunction with other measurements of emotion regulation, stress responsivity, irritability, and reactive aggression11,12 to better understand overlapping constructs (ie, how they differ, and where they overlap). A suitable outburst measure7,13 could consider duration, frequency, severity, context (including precipitating factors), impairment, and recovery time to baseline. If there are existing datasets that can be reconfigured to describe outbursts, an attempt should be made to mine these datasets for information on outbursts. For example, the Taskforce asks, “Can natural language processing of existing clinical datasets be utilized, or do researchers need to first develop consensus about how to consistently describe outbursts in clinical datasets? How can community partners, families, and those with lived experience participate in the development of a measure?”
Following its development, a measure for outbursts should be tested in a large, representative, normative sample, with clinical oversampling to determine age, sex/gender, and cultural norms across informants. This measure should then be collected in a conjunction with existing measures of emotion regulation, irritability, cognition, and psychopathology to gather an understanding of the relations among these constructs. There should be an examination of whether this measure can be modified or another measure developed that is sensitive enough to change that it can be used as an outcome measure in clinical trials. Successful studies could use wearables and/or ecological momentary assessment in the real-time measurement of outbursts.
Describing the Association Between Outbursts and Other Conditions
There is a need to study the relations among psychiatric diagnoses that may include outbursts and addressing the question of whether outbursts are truly transdiagnostic14 (in that they occur with the same pathophysiology regardless of etiology) or whether there are qualitative or quantitative differences in outbursts that arise as a function of a particular diagnosis or a particular underlying neurobiology. Although youth who have had adverse or traumatic experiences crowd psychiatric emergency departments and residential treatment settings because of behavioral outbursts and emotional dysregulation, there is a dearth of trauma research literature focused on outbursts or emotional regulation problems in children and adolescents with post-traumatic stress disorder.3,15, 16, 17, 18, 19 Despite considerable research in these areas,17,20 there remains little understanding of the relations between outbursts and Research Domain Criteria (RDoC) constructs of frustrative non-reward, attention, cognitive control, social communication, sleep, and wakefulness. To supplement the call for research regarding emotion regulation, irritability, and outbursts, these additional areas may be prime for investigation and validation both in humans and in animal models. Gaps remain in the literature between the phenotypic substrates of outbursts observed in humans and their translation into and from animal models, as there are relatively few animal models that relate to outbursts. There may be good reasons for cross-species modeling, as outbursts are relatively common in the animal world and sex differentiated.21, 22, 23
Understanding the Pathophysiology and Natural History of Outbursts
Individual variation in the propensity for outbursts can be operationalized by (a) the frequency, severity, and duration of the behaviors themselves; (b) the level of stress or provocation required to elicit a dysregulated behavioral response (this varies markedly across individuals) and the time that it takes to return to baseline emotional regulation; or (c) the level of emotional arousal that occurs in response to a stressor of a given stimulus intensity.24 Although the characterization of the behaviors themselves may be useful for categorizing patients for clinical purposes such as deciding on appropriate levels of care, for other clinical purposes, categories defined by the phenomenological commonality of outbursts can also be scientifically misleading. Specifically, agitated behavior seen in Tourette syndrome, psychotic disorder, post-traumatic stress disorder, oppositional defiant disorder, mood disorders, attention-deficit/hyperactivity disorder, or in response to other provocation may be within the phenocopies25 rather than representing the same phenomenon. Any feasible measure would need to standardize the level of emotional arousal along with the level of stimulus intensity of a given stressor. The relation between emotional arousal and stimulus intensity will determine how outbursts are associated with impulse control, emotional arousal, and the magnitude of intensity of a given stressor. Outbursts may occur only when a stressor leads to emotional arousal exceeding the threshold for controlling the impulse to act in a maladaptive/dysregulated manner. Outbursts must be contextualized with verbal, cognitive, developmental, and adaptive skills in mind to determine capacity for learning and skill development for treatment planning.26 Moreover, an understanding of how these thresholds may differ in youth with an experience of trauma is also necessary.
In addition to mining other large datasets, longitudinal datasets that describe components of outbursts should be examined to determine the outcome of outbursts across childhood and into adulthood. A well-defined measure of outbursts may advance understanding of relations among emotion dysregulation, irritability, and other facets of psychopathology over time. Do they uniquely predict differential outcomes, or do they uniformly predict similarly poor outcomes based on severity? The taskforce also discussed the need for outburst measures within the adult psychiatric population. At this time, these are only ascertained in the context of intermittent explosive disorder, so it is unclear what outburst behavior looks like across development into adulthood. It is possible that children categorized with experiencing outbursts will outgrow the outburst behavior, or that such behaviors will continue in the form of domestic violence, road rage, or other aggressive acts. As mentioned above, there is a further outstanding question as to whether wearables or psychophysiological measurement can be used to predict whether an outburst will occur or will help the patient manage an outburst, as measurement and management of outbursts can be challenging after they begin or at the peak of their severity.
Exploring the Cultural, Social, and Interpersonal Aspects of Outbursts
Little is known about the cultural, clinical, racial, and sex/gender biases in reporting and treatment of outbursts. Relatedly, it is imperative to understand the role of parental emotion regulation and interactions with the youth in the initiation, prolongation, and termination of their outbursts. Here, again, an adult measure of outbursts may also be useful. Similarly, we do not have a full understanding of which outbursts are pathological and what the utility of outbursts are for the particular family and their interaction.27 From a social and environmental standpoint, there should be efforts made to understand what constitutes outbursts and the effects of discrimination on youth with outbursts across cultures.28 For example, the experience of an outburst in specific cultures, especially as it relates to the experience of the individual and family in that culture, is poorly understood. Little is known, for instance, about the role that a history of discrimination has on the expression and the perception of an outburst, as well as the effects of social media on emotion regulation generally and on outbursts specifically. A careful accounting of the economic costs of managing outbursts in various settings should be undertaken. From a workforce perspective, it would be prudent to gain an understanding of how exposure to youth with impairing outbursts might affect recruitment into the fields of child and adolescent psychiatry, psychology, and social work.29
Understanding the Prevention and Treatment of Outbursts Through Research
There is a paucity of research on the family history of outbursts or other characteristics such as traumatic exposures or adverse childhood experiences that make them more likely in a particular child that might be targets of primary prevention.30 Similarly, there is little known for secondary prevention of worsening outbursts once they occur. There is a critical need for clinical trial research of the management of acute outbursts, including more pharmacological trials,31 psychotherapeutic trials, and comparative effectiveness trials. There is a further need to examine premorbid and escalation patterns of outbursts, related dysregulated behaviors, and potential intervening variables to reduce youth needing to move to higher levels of care because of them. It is important to understand the role of debrief after outbursts, and how that should inform clinical interventions with the youth and family.
Differential effects of therapeutics on the components of emotion regulation, irritability, and outbursts have not been well studied. Little is known about whether treatment of each of these aspects should be done separately or the validity of a common treatment.32 Similarly, investigation of the characteristics of the patient or the outbursts themselves that may determine the efficacy of treatments has not been well studied. As treatments are developed and studied, there will be a need to characterize the duration of treatment. Outbursts may be persistent and chronic, yet most psychiatric interventions for outbursts target only acute symptoms. Will short-term interventions lead to long-term reduction in outbursts? If an adequate measure of outbursts can be obtained, there is a need to develop evidence-based interventions and to review the consequences of treatment (or lack) of outbursts.
Exploring Outbursts and Their Management Based on Setting
Schools are desperate for help in the management of outbursts.33 There is a need for a concise and an easy-to-implement approach for the characterization and management of outbursts in schools, as well as a guideline for referral to the emergency department/crisis services. Clear circumstances might lead a child to require leaving the school for help, but there are striking gaps in recommendations when the circumstances are unclear. Understanding the relation of time to recovery from an outburst may be particularly salient in this situation. Residential and inpatient programs need to know what systems will protect staff from injury associated with outbursts. They also need to know whether length of stay, staffing patterns or training, or intensity of treatment affect the various components of emotion regulation. Connecting the domains, understanding how disparities in health care impact youth of color who present in emergency departments with outbursts and emotional dysregulation is important.2,34,35 There is a need for outpatient, emergency department, residential, and inpatient/intensive outpatient programs to know whether there is an effectiveness of pro re nata (PRN) medications36, 37, 38 to manage an outburst. PRN medication is frequently given, but there is scant evidence that this use reduces the frequency, severity, or duration of an outburst. Similar to the treatment questions above, are the components of emotion dysregulation and outbursts differentially affected by PRN usage?
As a whole, difficulties with emotion regulation that manifest as outbursts appear to be among the most common reasons for referral of youth to psychiatric care, including the most intensive settings such as emergency department and inpatient/residential units. It is also apparent to the field that there are numerous unanswered and unstudied questions related to each of these domains. If these questions remain among the most experienced physicians and researchers in this direct field, it is not surprising that there is little guidance to the field in general, and to the leaders of the aforementioned youth settings. Despite the rising prevalence of this problem, there are clear gaps in the knowledge about how to measure and treat outbursts. Finally, as a taskforce, we recommend that funding agencies responsible for enhancing systems of care for the medically vulnerable (Health Resources & Services Administration [HRSA]), for the reduction of mental illness in America’s communities (Substance Abuse and Mental Health Services Administration [SAMHSA]), for leading research on mental disorders (National Institute of Mental Health [NIMH]), for improving health care delivery and outcomes (Patient-Centered Outcomes Research Institute [PCORI]), for setting the standards for child welfare in the United States (Children’s Bureau), and the Office of Juvenile Justice and Delinquency Prevention (OJJDP), examine the spaces within their strategic plans that will allow for engaging in these kinds of critical efforts to improve the lives of the most troubled youth in the nation—those with impairing emotional outbursts—and their families.
CRediT authorship contribution statement
Robert R. Althoff: Writing – review & editing, Writing – original draft, Funding acquisition, Conceptualization. Manpreet K. Singh: Writing – review & editing, Writing – original draft, Conceptualization. Argyris Stringaris: Writing – review & editing, Writing – original draft, Conceptualization. John N. Constantino: Writing – review & editing, Writing – original draft, Conceptualization. Lisa Amaya-Jackson: Writing – review & editing. Tami D. Benton: Writing – review & editing. Christopher Bellonci: Writing – review & editing. Jeff Q. Bostic: Writing – review & editing. Jaclyn Datar Chua: Writing – review & editing. Robert L. Findling: Writing – review & editing. Cathryn A. Galanter: Writing – review & editing. Ruth S. Gerson: Writing – review & editing. Jon M. McClellan: Writing – review & editing. Michael T. Sorter: Writing – review & editing. James G. Waxmonsky: Writing – review & editing. Gabrielle A. Carlson: Writing – review & editing, Writing – original draft, Funding acquisition, Conceptualization.
Footnotes
This article was reviewed under and accepted by Ad Hoc Editor Joel Stoddard, MD, MAS.
The authors are appreciative of the support of the AACAP Presidential Fund and the support of the University of Vermont Department of Psychiatry for funds related to the Congress on Pediatric Irritability and Dysregulation.
This article is part of a special series devoted to addressing aggressive behavior as a focus of psychiatric attention and how its manifestations and treatment needs may vary across psychiatric disorders. The series is edited by Guest Editor Joseph Blader, PhD, Deputy Editor Robert Findling, MD, MBA, and Editor Manpreet K. Singh, MD, MS.
The authors are appreciative of the participants in the 4th and 5th Congress on Pediatric Irritability and Dysregulation who informed this work and to Hannah Frering, MPH, at the University of Vermont, who organized the conference in Burlington.
Disclosure: Robert A. Althoff has received grant support from NIH and the Klingenstein Third Generation Foundation, honoraria for an editorial position at JAACAP and for presentations at the MGH Psychiatry Academy, and has an ownership interest in WISER Systems, LLC. Manpreet K. Singh has received grant or research support from NIH, PCORI, BBRF, Johnson & Johnson, and Allergan. She has served as a consultant or on the advisory board or DSMB for Sunovian, Alkermes, Skyland Trail, X, moonshot factor, Alphabet, Inc., Limbix Health and has received royalties from Thrive Global and American Psychiatric Association Publishing. Lisa Amaya-Jackson has received research support from SAMHSA. Robert L. Findling has received research support, acted as a consultant, and/or has received honoraria from Abbvie, Acadia, Adamas, Afecta, Ajna, Akili, Alkermes, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, BioXcel, Idorsia, Iqvia, Lundbeck, MJH Life Sciences, Neurim, NIH, Novartis, Otsuka, Oxford University Press, PaxMedica, PCORI, Pfizer, Physicians’ Postgraduate Press, Radius, Receptor Life Sciences, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Takeda, Tris, and Viatris. James G. Waxmonsky has received research funding from Supernus and has served as a consultant for Iron Shore. Argyris Stringaris, John N. Constantino, Tami D. Benton, Christopher Bellonci, Jeff Q. Bostic, Jaclyn Datar Chua, Cathryn A. Galanter, Ruth S. Gerson, Jon M. McClellan, Michael T. Sorter, and Gabrielle A. Carlson have reported no biomedical financial interests or potential conflicts of interest.
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