Log in

Management of Emotion Dysregulation and Outbursts in Children and Adolescents

  • Child and Adolescent Disorders (TD Benton, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

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.

Summary

Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Baker M, Carlson GA. What do we really know about PRN use in agitated children with mental health conditions: a clinical review. Evid Based Ment Health. 2018;21(4):166–70.

    PubMed  Google Scholar 

  2. Masters KJ, Bellonci C. Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. J Am Acad Child Adolesc Psychiatry. 2002;41(2):4S-25S.

    PubMed  Google Scholar 

  3. Bunford N, Evans SW, Wymbs F. ADHD and emotion dysregulation among children and adolescents. Clin Child Fam Psychol Rev. 2015;18(3):185–217.

    PubMed  Google Scholar 

  4. Carlson GA, Potegal M, Margulies D, Gutkovich Z, Basile J. Rages—what are they and who has them? J Child Adolesc Psychopharmacol. 2009;19(3):281–8.

    PubMed  PubMed Central  Google Scholar 

  5. Sharma A, McClellan J. Emotional and behavioral dysregulation in severe mental illness. Child and Adolescent Psychiatric Clinics. 2021.

  6. Keeshin BR, Bryant BJ, Gargaro ER. Emotional dysregulation: a trauma-informed approach. Child Adolesc Psychiatr Clin N Am. 2021;30(2):375–87.

    PubMed  Google Scholar 

  7. Benton TD, Muhrer E, Jones JD, Lewis J. Dysregulation and suicide in children and adolescents. Child and Adolescent Psychiatric Clinics. 2021.

  8. Cai RY, Richdale AL, Uljarević M, Dissanayake C, Samson AC. Emotion regulation in autism spectrum disorder: Where we are and where we need to go. Autism Res. 2018;11(7):962–78.

    PubMed  Google Scholar 

  9. Bostic JQ, Mattison R, Cunningham D. Explosive outbursts at school. Child Adolesc Psychiatr Clin N Am. 2021;30(3):491–503.

    PubMed  Google Scholar 

  10. Althoff RR, Verhulst FC, Rettew DC, Hudziak JJ, van der Ende J. Adult outcomes of childhood dysregulation: a 14-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2010;49(11):1105–16. e1.

  11. Copeland WE, Shanahan L, Egger H, Angold A, Costello EJ. Adult diagnostic and functional outcomes of DSM-5 disruptive mood dysregulation disorder. Am J Psychiatry. 2014;171(6):668–74.

    PubMed  PubMed Central  Google Scholar 

  12. Meyer SE, Carlson GA, Youngstrom E, Ronsaville DS, Martinez PE, Gold PW, et al. Long-term outcomes of youth who manifested the CBCL-Pediatric Bipolar Disorder phenotype during childhood and/or adolescence. J Affect Disord. 2009;113(3):227–35.

    PubMed  Google Scholar 

  13. Spring L, Carlson GA. The phenomenology of outbursts. Child Adolesc Psychiatr Clin N Am. 2021;30(2):307–19.

    PubMed  Google Scholar 

  14. Connor DF, Newcorn JH, Saylor KE, Amann BH, Scahill L, Robb AS, et al. Maladaptive aggression: with a focus on impulsive aggression in children and adolescents. J Child Adolesc Psychopharmacol. 2019;29(8):576–91.

    PubMed  PubMed Central  Google Scholar 

  15. Connor DF, Doerfler LA. The many faces (and names) of mood dysregulation. Child Adolesc Psychiatr Clin N Am. 2021;30(2):299–306.

    PubMed  Google Scholar 

  16. Bambauer KZ, Connor DF. Characteristics of aggression in clinically referred children. CNS Spectr. 2005;10(9):709–18.

    PubMed  Google Scholar 

  17. Althoff RR. Dysregulated Children Reconsidered. J Am Acad Child Adolesc Psychiatry. 2010;49(4):302-5.

  18. Althoff RR, Ametti M. Measurement of dysregulation in children and adolescents. Child and Adolescent Psychiatric Clinics. 2021.

  19. Ametti M, Althoff RR. Measurement of irritability. Irritability in pediatric psychopathology. 2019:29.

  20. Graziano PA, Garcia A. Attention-deficit hyperactivity disorder and children’s emotion dysregulation: a meta-analysis. Clin Psychol Rev. 2016;46:106–23.

    PubMed  Google Scholar 

  21. Cole PM, Martin SE, Dennis TA. Emotion regulation as a scientific construct: methodological challenges and directions for child development research. Child Dev. 2004;75(2):317–33.

    PubMed  Google Scholar 

  22. Graziano PA, Hart K. Beyond behavior modification: benefits of social–emotional/self-regulation training for preschoolers with behavior problems. J Sch Psychol. 2016;58:91–111.

    PubMed  Google Scholar 

  23. Waxmonsky JG, Baweja R, Bansal PS, Waschbusch DA. A review of the evidence base for psychosocial interventions for the treatment of emotion dysregulation in children and adolescents. Child and Adolescent Psychiatric Clinics. 2021;30(3):573–94.

    Google Scholar 

  24. Goodman A, Goodman R. Strengths and difficulties questionnaire as a dimensional measure of child mental health. J Am Acad Child Adolesc Psychiatry. 2009;48(4):400–3.

    PubMed  Google Scholar 

  25. Carballo JJ, Serrano-Drozdowskyj E, Nieto RG, de Neira-Hernando MD, Pérez-Fominaya M, Molina-Pizarro CA, et al. Prevalence and correlates of psychopathology in children and adolescents evaluated with the strengths and difficulties questionnaire dysregulation profile in a clinical setting. Psychopathology. 2014;47(5):303–11.

    PubMed  Google Scholar 

  26. Kunze B, Wang B, Isensee C, Schlack R, Ravens-Sieberer U, Klasen F, et al. Gender associated developmental trajectories of SDQ-dysregulation profile and its predictors in children. Psychol Med. 2018;48(3):404–15.

    CAS  PubMed  Google Scholar 

  27. Ratey JJ, Gutheil CM. The measurement of aggressive behavior: Reflections on the use of the Overt Aggression Scale and the modified Overt Aggression Scale. J Neuropsychiatry Clin Neurosci. 1991.

  28. Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986.

  29. Sorgi P, Ratey JJ, Knoedler DW, Markert RJ, Reichman M. Rating aggression in the clinical setting: a retrospective adaptation of the Overt Aggression Scale: Preliminary results. J Neuropsychiatry Clin Neurosci. 1991.

  30. Kho K, Sensky T, Mortimer A, Corcos C. Prospective study into factors associated with aggressive incidents in psychiatric acute admission wards. Br J Psychiatry. 1998;172(1):38–43.

    CAS  PubMed  Google Scholar 

  31. Oliver P, Crawford M, Rao B, Reece B, Tyrer P. Modified Overt Aggression Scale (MOAS) for people with intellectual disability and aggressive challenging behaviour: a reliability study. J Appl Res Intellect Disabil. 2007;20(4):368–72.

    Google Scholar 

  32. Barzman DH, Brackenbury L, Sonnier L, Schnell B, Cassedy A, Salisbury S, et al. Brief Rating of Aggression by Children and Adolescents (BRACHA): development of a tool for assessing risk of inpatients’ aggressive behavior. Journal of the American Academy of Psychiatry and the Law Online. 2011;39(2):170–9.

    Google Scholar 

  33. Stringaris A, Goodman R, Ferdinando S, Razdan V, Muhrer E, Leibenluft E, et al. The Affective Reactivity Index: a concise irritability scale for clinical and research settings. J Child Psychol Psychiatry. 2012;53(11):1109–17.

    PubMed  PubMed Central  Google Scholar 

  34. Neumann A, van Lier PA, Gratz KL, Koot HM. Multidimensional assessment of emotion regulation difficulties in adolescents using the difficulties in emotion regulation scale. Assessment. 2010;17(1):138–49.

    PubMed  Google Scholar 

  35. Kaufman EA, **a M, Fosco G, Yaptangco M, Skidmore CR, Crowell SE. The Difficulties in Emotion Regulation Scale Short Form (DERS-SF): validation and replication in adolescent and adult samples. J Psychopathol Behav Assess. 2016;38(3):443–55.

    Google Scholar 

  36. Evans SC, Santucci L. A Modular, Transdiagnostic approach to treating severe irritability in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2021;30(3):623–36.

    PubMed  Google Scholar 

  37. Salem T, Walters KA, Verducci JS, Fristad MA. Psychoeducational and skill-building interventions for emotion dysregulation. Child Adolesc Psychiatr Clin N Am. 2021;30(3):611–22.

    PubMed  Google Scholar 

  38. Stringaris A, Vidal-Ribas P, Brotman MA, Leibenluft E. Practitioner review: definition, recognition, and treatment challenges of irritability in young people. J Child Psychol Psychiatry. 2018;59(7):721–39.

    PubMed  Google Scholar 

  39. Vacher C, Goujon A, Romo L, Purper-Ouakil D. Efficacy of psychosocial interventions for children with ADHD and emotion dysregulation: a systematic review. Psychiatry Res. 2020;291:113151.

  40. Kazdin AE. Parent management training: evidence, outcomes, and issues. J Am Acad Child Adolesc Psychiatry. 1997;36(10):1349–56.

    CAS  PubMed  Google Scholar 

  41. Comer JS, Chow C, Chan PT, Cooper-Vince C, Wilson LA. Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination. J Am Acad Child Adolesc Psychiatry. 2013;52(1):26–36.

    PubMed  Google Scholar 

  42. Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Campbell Syst Rev. 2012;8(1):1–239.

    Google Scholar 

  43. Crick NR, Dodge KA. A review and reformulation of social information-processing mechanisms in children’s social adjustment. Psychol Bull. 1994;115(1):74.

    Google Scholar 

  44. Aman MG, Mcdougle CJ, Scahill L, Handen B, Arnold LE, Johnson C, et al. Medication and parent training in children with pervasive developmental disorders and serious behavior problems: results from a randomized clinical trial. J Am Acad Child Adolesc Psychiatry. 2009;48(12):1143–54.

    PubMed  Google Scholar 

  45. Rothenberg WA, Weinstein A, Dandes EA, Jent JF. Improving child emotion regulation: effects of parent–child interaction-therapy and emotion socialization strategies. J Child Fam Stud. 2019;28(3):720–31.

    Google Scholar 

  46. Johnson M, Östlund S, Fransson G, Landgren M, Nasic S, Kadesjö B, et al. Attention-deficit/hyperactivity disorder with oppositional defiant disorder in Swedish children–an open study of collaborative problem solving. Acta Paediatr. 2012;101(6):624–30.

    PubMed  Google Scholar 

  47. Thornback K, Muller RT. Relationships among emotion regulation and symptoms during trauma-focused CBT for school-aged children. Child Abuse Negl. 2015;50:182–92.

    PubMed  Google Scholar 

  48. Luby J, Lenze S, Tillman R. A novel early intervention for preschool depression: findings from a pilot randomized controlled trial. J Child Psychol Psychiatry. 2012;53(3):313–22.

    PubMed  Google Scholar 

  49. Luby JL, Barch DM, Whalen D, Tillman R, Freedland KE. A randomized controlled trial of parent-child psychotherapy targeting emotion development for early childhood depression. Am J Psychiatry. 2018;175(11):1102–10.

    PubMed  PubMed Central  Google Scholar 

  50. Fristad MA, Vesco AT, Young AS, Healy KZ, Nader ES, Gardner W, et al. Pilot randomized controlled trial of omega-3 and individual–family psychoeducational psychotherapy for children and adolescents with depression. J Clin Child Adolesc Psychol. 2019;48(sup1):S105–18.

    PubMed  Google Scholar 

  51. Evans SC, Weisz JR, Carvalho AC, Garibaldi PM, Bearman SK, Chorpita BF, et al. Effects of standard and modular psychotherapies in the treatment of youth with severe irritability. J Consult Clin Psychol. 2020;88(3):255–68.

    PubMed  Google Scholar 

  52. Apsche JA, Bass CK, Jennings JL, Siv AM. A review and empirical comparison of two treatments for adolescent males with conduct and personality disorder: Mode Deactivation Therapy and Cognitive Behavior Therapy. Int J Behav Consult Ther. 2005;1(1):27.

    Google Scholar 

  53. Greene RW, Ablon JS, Martin A. Use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units. Psychiatr Serv. 2006;57(5):610–2.

    PubMed  Google Scholar 

  54. Gathright MM, Holmes KJ, Morris EM, Gatlin DA. An innovative, interdisciplinary model of care for inpatient child psychiatry: an overview. J Behav Health Serv Res. 2016;43(4):648–60.

    PubMed  Google Scholar 

  55. James S, Alemi Q, Zepeda V. Effectiveness and implementation of evidence-based practices in residential care settings. Child Youth Serv Rev. 2013;35(4):642–56.

    PubMed  PubMed Central  Google Scholar 

  56. Delaney KR. Top 10 milieu interventions for inpatient child/adolescent treatment. J Child Adolesc Psychiatr Nurs. 2006;19(4):203–14.

    PubMed  Google Scholar 

  57. Dean AJ, Duke SG, George M, Scott J. Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit. J Am Acad Child Adolesc Psychiatry. 2007;46(6):711–20.

    PubMed  Google Scholar 

  58. Reynolds EK, Grados MA, Praglowski N, Hankinson JC, Deboard-Lucas R, Goldstein L, et al. Use of modified positive behavioral interventions and supports in a psychiatric inpatient unit for high-risk youths. Psychiatr Serv. 2016;67(5):570–3.

    PubMed  Google Scholar 

  59. Carlson GA, Chua J, Pan K, Hasan T, Bied A, Martin A, et al. Behavior modification is associated with reduced psychotropic medication use in children with aggression in inpatient treatment: a retrospective cohort study. J Am Acad Child Adolesc Psychiatry. 2020;59(5):632–41. e4.

  60. Pollastri AR, Lieberman RE, Boldt SL, Ablon JS. Minimizing seclusion and restraint in youth residential and day treatment through site-wide implementation of collaborative problem solving. Residential Treatment for Children & Youth. 2016;33(3–4):186–205.

    Google Scholar 

  61. Tebbett-Mock AA, Saito E, McGee M, Woloszyn P, Venuti M. Efficacy of dialectical behavior therapy versus treatment as usual for acute-care inpatient adolescents. J Am Acad Child Adolesc Psychiatry. 2020;59(1):149–56.

    PubMed  Google Scholar 

  62. Leffler JM. Evaluating the clinical and financial outcomes of implementing dialectical behavior therapy on a psychiatric inpatient unit: a change in practice and culture. J Am Acad Child Adolesc Psychiatry. 2019;59(1):40–2.

    PubMed  Google Scholar 

  63. Jonikas JA, Cook JA, Rosen C, Laris A, Kim J-B. A program to reduce use of physical restraint in psychiatric inpatient facilities. Psychiatr Serv. 2004;55(7):818–20.

    PubMed  Google Scholar 

  64. Delaney KR. Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment. Worldviews Evid.-Based Nurs. 2006;3(1):19–30.

    PubMed  Google Scholar 

  65. LeBel J, Goldstein R. Special section on seclusion and restraint: the economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatr Serv. 2005;56(9):1109–14.

    PubMed  Google Scholar 

  66. LeBel J, Stromberg N, Duckworth K, Kerzner J, Goldstein R, Weeks M, et al. Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care. J Am Acad Child Adolesc Psychiatry. 2004;43(1):37–45.

    PubMed  Google Scholar 

  67. Azeem MW, Aujla A, Rammerth M, Binsfeld G, Jones RB. Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. J Child Adolesc Psychiatr Nurs. 2011;24(1):11–5.

    PubMed  Google Scholar 

  68. Wisdom JP, Wenger D, Robertson D, Van Bramer J, Sederer LI. The New York state office of mental health positive alternatives to restraint and seclusion (PARS) project. Psychiatr Serv. 2015;66(8):851–6.

    PubMed  Google Scholar 

  69. Donovan A, Plant R, Peller A, Siegel L, Martin A. Two-year trends in the use of seclusion and restraint among psychiatrically hospitalized youths. Psychiatr Serv. 2003;54(7):987–93.

    PubMed  Google Scholar 

  70. Blake CS, Hamrin V. Current approaches to the assessment and management of anger and aggression in youth: a review. J Child Adolesc Psychiatr Nurs. 2007;20(4):209–21.

    PubMed  Google Scholar 

  71. Coleman M, Pfeiffer S, Oakland T. Aggression replacement training with behaviorally disordered adolescents. Behav Disord. 1992;18(1):54–66.

    Google Scholar 

  72. Connor DF, Miller KP, Cunningham JA, Melloni RH Jr. What does getting better mean? Child improvement and measure of outcome in residential treatment. Am J Orthopsychiatry. 2002;72(1):110–7.

    PubMed  Google Scholar 

  73. Huefner JC, O’Brien C, Vollmer DG. Designing and testing a developmentally appropriate intervention for children in a psychiatric residential treatment facility. Child Adolesc Psychiatr Clin N Am. 2021;30(3):527–36.

    PubMed  Google Scholar 

  74. Chua JD, Bellonci C, Sorter MT. Treatment of childhood emotion dysregulation in inpatient and residential settings. Child Adolesc Psychiatr Clin N Am. 2021;30(3):505–25.

    PubMed  Google Scholar 

  75. Pappadopulos E, Macintyre Ii JC, Crismon ML, Findling RL, Malone RP, Derivan A, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II. J Am Acad Child Adolesc Psychiatry. 2003;42(2):145–61.

  76. Vaudreuil C, Farrell A, Wozniak J. Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics. 2021;30(3):537–60.

    Google Scholar 

  77. Abou-Setta AM, Mousavi SS, Spooner C, Schouten JR, Pasichnyk D, Armijo-Olivo S, et al. First-Generation Versus Second-Generation Antipsychotics in Adults: Comparative Effectiveness. Agency for Healthcare Research and Quality (US), Rockville (MD); 2012.

  78. Campbell M, Small AM, Green WH, Jennings SJ, Perry R, Bennett WG, et al. Behavioral efficacy of haloperidol and lithium carbonate: a comparison in hospitalized aggressive children with conduct disorder. Arch Gen Psychiatry. 1984;41(7):650–6.

    CAS  PubMed  Google Scholar 

  79. Greenhill LL, Solomon M, Pleak R, Ambrosini P. Molindone hydrochloride treatment of hospitalized children with conduct disorder. Journal Clin Psychiatry. 1985.

  80. Sikich L, Frazier JA, McClellan J, Findling RL, Vitiello B, Ritz L, et al. Double-blind comparison of first-and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the treatment of early-onset schizophrenia spectrum disorders (TEOSS) study. Am J Psychiatry. 2008;165(11):1420–31.

    PubMed  Google Scholar 

  81. Ceresoli-Borroni G, Nasser A, Adewole T, Liranso T, Xu J, Schwabe S, et al. A double-blind, randomized study of extended-release molindone for impulsive aggression in ADHD. J Atten Disord. 2020:1087054720909084.

  82. Juárez-Treviño M, Esquivel AC, Leal Isida LM, Galarza Delgado DÁ, de la O Cavazos ME, Garza Ocañas L, et al. Clozapine in the treatment of aggression in conduct disorder in children and adolescents: a randomized, double-blind, controlled trial. Clin Psychopharmacol Neurosci. 2019.

  83. Findling RL, McNAMARA NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(4):509–16.

    CAS  PubMed  Google Scholar 

  84. Krieger FV, Pheula GF, Coelho R, Zeni T, Tramontina S, Zeni CP, et al. An open-label trial of risperidone in children and adolescents with severe mood dysregulation. J Child Adolesc Psychopharmacol. 2011;21(3):237–43.

    CAS  PubMed  Google Scholar 

  85. Aman MG, Bukstein OG, Gadow KD, Arnold LE, Molina BS, McNamara NK, et al. What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry. 2014;53(1):47–60. e1.

  86. Pan P-Y, Fu A-T, Yeh C-B. Aripiprazole/methylphenidate combination in children and adolescents with disruptive mood dysregulation disorder and attention-deficit/hyperactivity disorder: an open-label study. J Child Adolesc Psychopharmacol. 2018;28(10):682–9.

    CAS  PubMed  Google Scholar 

  87. Pappadopulos E, Woolston S, Chait A, Perkins M, Connor DF, Jensen PS. Pharmacotherapy of Aggression in Children and Adolescents: Efficacy and Effect Size. J Can Acad Child Adolesc Psychiatry/Journal de L'Académie Canadienne de Psychiatrie de L'enfant et de L'Adolescent. 2006.

  88. Gamli IS, Tahiroglu AY. Six months methylphenidate treatment improves emotion dysregulation in adolescents with attention deficit/hyperactivity disorder: a prospective study. Neuropsychiatr Dis Treat. 2018;14:1329.

    CAS  Google Scholar 

  89. Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S. Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry. 1997;54(12):1073–80.

    CAS  PubMed  Google Scholar 

  90. Waxmonsky J, Pelham WE, Gnagy E, Cummings MR, O’Connor B, Majumdar A, et al. The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation. J Child Adolesc Psychopharmacol. 2008;18(6):573–88.

    PubMed  PubMed Central  Google Scholar 

  91. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni Jr RH. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression–related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry. 2002;41(3):253–61.

  92. Blader JC, Pliszka SR, Kafantaris V, Foley CA, Carlson GA, Crowell JA, et al. Stepped treatment for attention-deficit/hyperactivity disorder and aggressive behavior: a randomized, controlled trial of adjunctive risperidone, divalproex sodium, or placebo after stimulant medication optimization. J Am Acad Child Adolesc Psychiatry. 2021;60(2):236–51.

    PubMed  Google Scholar 

  93. Barzman DH, McConville BJ, Masterson B, McElroy S, Sethuraman G, Moore K, et al. Impulsive aggression with irritability and responsive to divalproex: a pediatric bipolar spectrum disorder phenotype? J Affect Disord. 2005;88(3):279–85.

    CAS  PubMed  Google Scholar 

  94. Pisano S, Pozzi M, Catone G, Scrinzi G, Clementi E, Coppola G, et al. Putative mechanisms of action and clinical use of lithium in children and adolescents: a critical review. Curr Neuropharmacol. 2019;17(4):318–41.

    CAS  PubMed  PubMed Central  Google Scholar 

  95. Hafeman DM, Rooks B, Merranko J, Liao F, Gill MK, Goldstein TR, et al. Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1146–55.

    PubMed  Google Scholar 

  96. Campbell M, Adams PB, Small AM, Kafantaris V, Silva RR, Shell J, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1995;34(4):445–53.

    CAS  PubMed  Google Scholar 

  97. Malone RP, Delaney MA, Luebbert JF, Cater J, Campbell M. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry. 2000;57(7):649–54.

    CAS  PubMed  Google Scholar 

  98. Rifkin A, Karajgi B, Dicker R, Perl E, Boppana V, Hasan N, et al. Lithium treatment of conduct disorders in adolescents. Am J Psychiatry. 1997;154(4):554–5.

    CAS  PubMed  Google Scholar 

  99. Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, et al. Randomized double-blind placebo-controlled trial of lithium in youths with severe mood dysregulation. J Child Adolesc Psychopharmacol. 2009;19(1):61–73.

    PubMed  PubMed Central  Google Scholar 

  100. Sallee FR, Kollins SH, Wigal TL. Efficacy of guanfacine extended release in the treatment of combined and inattentive only subtypes of attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2012;22(3):206–14.

    CAS  PubMed  PubMed Central  Google Scholar 

  101. Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev. 2017(8).

  102. Marcus RN, Owen R, Kamen L, Manos G, McQuade RD, Carson WH, et al. A placebo-controlled, fixed-dose study of aripiprazole in children and adolescents with irritability associated with autistic disorder. J Am Acad Child Adolesc Psychiatry. 2009;48(11):1110–9.

    PubMed  Google Scholar 

  103. Findling RL, Mankoski R, Timko K, Lears K, McCartney T, McQuade RD, et al. A randomized controlled trial investigating the safety and efficacy of aripiprazole in the long-term maintenance treatment of pediatric patients with irritability associated with autistic disorder. J Clin Psychiatry. 2014;75(1):0-.

  104. Winters D, Fukui S, Leibenluft E, Hulvershorn L. Improvements in irritability with open-label methylphenidate treatment in youth with comorbid attention deficit/hyperactivity disorder and disruptive mood dysregulation disorder. J Child Adolesc Psychopharmacol. 2018;28.

  105. Barzman DH, DelBello MP, Adler CM, Stanford KE, Strakowski SM. The efficacy and tolerability of quetiapine versus divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorder (s). J Child Adolesc Psychopharmacol. 2006;16(6):665–70.

    PubMed  Google Scholar 

  106. Blader JC, Schooler NR, Jensen PS, Pliszka SR, Kafantaris V. Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy. Am J Psychiatry. 2009;166(12):1392–401.

    PubMed  PubMed Central  Google Scholar 

  107. Balia C, Carucci S, Coghill D, Zuddas A. The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous—unemotional traits modulate the efficacy of medication? Neurosci Biobehav Rev. 2018;91:218–38.

  108. Rucklidge JJ, Eggleston MJ, Johnstone JM, Darling K, Frampton CM. Vitamin-mineral treatment improves aggression and emotional regulation in children with ADHD: a fully blinded, randomized, placebo-controlled trial. J Child Psychol Psychiatry. 2018;59(3):232–46.

    PubMed  Google Scholar 

  109. Mayes SD, Calhoun SL, Waschbusch DA, Baweja R. Autism and reactive attachment/disinhibited social engagement disorders: co-occurrence and differentiation. Clin Child Psychol Psychiatry. 2017;22(4):620–31.

    PubMed  Google Scholar 

  110. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatry. 2008;47(8):921–9.

    PubMed  Google Scholar 

  111. Leyfer OT, Folstein SE, Bacalman S, Davis NO, Dinh E, Morgan J, et al. Comorbid psychiatric disorders in children with autism: interview development and rates of disorders. J Autism Dev Disord. 2006;36(7):849–61.

    PubMed  Google Scholar 

  112. Jahromi LB, Meek SE, Ober-Reynolds S. Emotion regulation in the context of frustration in children with high functioning autism and their typical peers. J Child Psychol Psychiatry. 2012;53(12):1250–8.

    PubMed  Google Scholar 

  113. Rieffe C, Meerum Terwogt M, Kotronopoulou K. Awareness of single and multiple emotions in high-functioning children with autism. J Autism Dev Disord. 2007;37(3):455–65.

    PubMed  Google Scholar 

  114. Conner CM, White SW, Scahill L, Mazefsky CA. The role of emotion regulation and core autism symptoms in the experience of anxiety in autism. Autism. 2020;24(4):931–40.

    PubMed  PubMed Central  Google Scholar 

  115. Mazefsky CA, Borue X, Day TN, Minshew NJ. Emotion regulation patterns in adolescents with high-functioning autism spectrum disorder: comparison to typically develo** adolescents and association with psychiatric symptoms. Autism Res. 2014;7(3):344–54.

    PubMed  PubMed Central  Google Scholar 

  116. Weiss JA. Transdiagnostic case conceptualization of emotional problems in youth with ASD: an emotion regulation approach. Clin Psychol (New York). 2014;21(4):331–50.

    Google Scholar 

  117. Shaffer RC, Reisinger D, Schmitt LM, Lamy M, Dominick K, Coffman M, et al. Systematic review: emotion dysregulation in syndromic causes of intellectual disabilities. J Am Acad Child Adolesc Psychiatry. (In Review).

  118. Mazefsky CA, Herrington J, Siegel M, Scarpa A, Maddox BB, Scahill L, et al. The role of emotion regulation in autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2013;52(7):679–88.

    PubMed  PubMed Central  Google Scholar 

  119. Samson AC, Hardan AY, Lee IA, Phillips JM, Gross JJ. Maladaptive behavior in autism spectrum disorder: the role of emotion experience and emotion regulation. J Autism Dev Disord. 2015;45(11):3424–32.

    PubMed  Google Scholar 

  120. Conner CM, Golt J, Shaffer R, Righi G, Siegel M, Mazefsky CA. Emotion dysregulation is substantially elevated in autism compared to the general population: impact on psychiatric services. Autism Res. 2021;14(1):169–81.

    PubMed  Google Scholar 

  121. Queen AH, Barlow DH, Ehrenreich-May J. The trajectories of adolescent anxiety and depressive symptoms over the course of a transdiagnostic treatment. J Anxiety Disord. 2014;28(6):511–21.

    PubMed  Google Scholar 

  122. Afshari A, Neshat-Doost HT, Maracy MR, Ahmady MK, Amiri S. The effective comparison between emotion-focused cognitive behavioral group therapy and cognitive behavioral group therapy in children with separation anxiety disorder. J Res Med Sci. 2014;19(3):221–7.

    PubMed  PubMed Central  Google Scholar 

  123. White SW, Simmons GL, Gotham KO, Conner CM, Smith IC, Beck KB, et al. Psychosocial treatments targeting anxiety and depression in adolescents and adults on the autism spectrum: review of the latest research and recommended future directions. Curr Psychiatry Rep. 2018;20(10):82.

    PubMed  PubMed Central  Google Scholar 

  124. Maddox BB, Crabbe S, Beidas RS, Brookman-Frazee L, Cannuscio CC, Miller JS, et al. “I wouldn’t know where to start”: perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults. Autism. 2020;24(4):919–30.

    PubMed  Google Scholar 

  125. Mazefsky CA, Yu L, White SW, Siegel M, Pilkonis PA. The emotion dysregulation inventory: psychometric properties and item response theory calibration in an autism spectrum disorder sample. Autism Res. 2018;11(6):928–41.

    PubMed  PubMed Central  Google Scholar 

  126. Mazefsky CA, Yu L, Pilkonis PA. Psychometric properties of the emotion dysregulation inventory in a nationally representative sample of youth. J Clin Child Adolesc Psychol. 2020:1–13.

  127. Factor RS, Swain DM, Antezana L, Muskett A, Gatto AJ, Radtke SR, et al. Teaching emotion regulation to children with autism spectrum disorder: outcomes of the Stress and Anger Management Program (STAMP). Bull Menninger Clin. 2019;83(3):235–58.

    PubMed  Google Scholar 

  128. Shaffer RC, Wink LK, Ruberg J, Pittenger A, Adams R, Sorter M, et al. Emotion regulation intensive outpatient programming: development, feasibility, and acceptability. J Autism Dev Disord. 2019;49(2):495–508.

    PubMed  Google Scholar 

  129. Weiss JA, Thomson K, Burnham Riosa P, Albaum C, Chan V, Maughan A, et al. A randomized waitlist-controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism. J Child Psychol Psychiatry. 2018;59(11):1180–91.

    PubMed  PubMed Central  Google Scholar 

  130. Conner CM, White SW, Beck KB, Golt J, Smith IC, Mazefsky CA. Improving emotion regulation ability in autism: the Emotional Awareness and Skills Enhancement (EASE) program. Autism. 2019;23(5):1273–87.

    PubMed  Google Scholar 

  131. Jobski K, Hofer J, Hoffmann F, Bachmann C. Use of psychotropic drugs in patients with autism spectrum disorders: a systematic review. Acta Psychiatr Scand. 2017;135(1):8–28.

    CAS  PubMed  Google Scholar 

  132. Sochocky N, Milin R. Second generation antipsychotics in Asperger’s Disorder and high functioning autism: a systematic review of the literature and effectiveness of meta-analysis. Curr Clin Pharmacol. 2013;8(4):370–9.

    CAS  PubMed  Google Scholar 

  133. Hollander E, Wasserman S, Swanson EN, Chaplin W, Schapiro ML, Zagursky K, et al. A double-blind placebo-controlled pilot study of olanzapine in childhood/adolescent pervasive developmental disorder. J Child Adolesc Psychopharmacol. 2006;16(5):541–8.

    PubMed  Google Scholar 

  134. Dominick K, Wink LK, McDougle CJ, Erickson CA. A retrospective naturalistic study of ziprasidone for irritability in youth with autism spectrum disorder. J Child Adolesc Psychopharmacol. 2015;25(5):397–401.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  135. Stigler KA, Mullett JE, Erickson CA, Posey DJ, McDougle CJ. Paliperidone for irritability in adolescents and young adults with autistic disorder. Psychopharmacology. 2012;223(2):237–45.

    CAS  PubMed  Google Scholar 

  136. Ching H, Pringsheim T. Aripiprazole for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012(5):Cd009043.

  137. Hollander E, Chaplin W, Soorya L, Wasserman S, Novotny S, Rusoff J, et al. Divalproex sodium vs placebo for the treatment of irritability in children and adolescents with autism spectrum disorders. Neuropsychopharmacology. 2010;35(4):990–8.

    CAS  PubMed  Google Scholar 

  138. Douglas JF, Sanders KB, Benneyworth MH, Smith JL, Dejean VM, McGrew SG, et al. Brief report: retrospective case series of oxcarbazepine for irritability/agitation symptoms in autism spectrum disorder. J Autism Dev Disord. 2013;43(5):1243–7.

    PubMed  Google Scholar 

  139. Kapetanovic S. Oxcarbazepine in youths with autistic disorder and significant disruptive behaviors. Am J Psychiatry. vol 5. United States 2007. p. 832–3.

  140. Belsito KM, Law PA, Kirk KS, Landa RJ, Zimmerman AW. Lamotrigine therapy for autistic disorder: a randomized, double-blind, placebo-controlled trial. J Autism Dev Disord. 2001;31(2):175–81.

    CAS  PubMed  Google Scholar 

  141. Siegel M, Beresford CA, Bunker M, Verdi M, Vishnevetsky D, Karlsson C, et al. Preliminary investigation of lithium for mood disorder symptoms in children and adolescents with autism spectrum disorder. J Child Adolesc Psychopharmacol. 2014;24(7):399–402.

    CAS  PubMed  Google Scholar 

  142. Fankhauser MP, Karumanchi VC, German ML, Yates A, Karumanchi SD. A double-blind, placebo-controlled study of the efficacy of transdermal clonidine in autism. J Clin Psychiatry. 1992;53(3):77–82.

    CAS  PubMed  Google Scholar 

  143. Scahill L, Aman MG, McDougle CJ, McCracken JT, Tierney E, Dziura J, et al. A prospective open trial of guanfacine in children with pervasive developmental disorders. J Child Adolesc Psychopharmacol. 2006;16(5):589–98.

    PubMed  Google Scholar 

  144. Scahill L, McCracken JT, King BH, Rockhill C, Shah B, Politte L, et al. Extended-release guanfacine for hyperactivity in children with autism spectrum disorder. Am J Psychiatry. 2015;172(12):1197–206.

    PubMed  Google Scholar 

  145. Reichow B, Volkmar FR, Bloch MH. Systematic review and meta-analysis of pharmacological treatment of the symptoms of attention-deficit/hyperactivity disorder in children with pervasive developmental disorders. J Autism Dev Disord. 2013;43(10):2435–41.

    PubMed  PubMed Central  Google Scholar 

  146. Handen BL, Johnson CR, Lubetsky M. Efficacy of methylphenidate among children with autism and symptoms of attention-deficit hyperactivity disorder. J Autism Dev Disord. 2000;30(3):245–55.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Michael Sorter.

Ethics declarations

Competing Interests

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Child and Adolescent Disorders

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sorter, M., Chua, J., Lamy, M. et al. Management of Emotion Dysregulation and Outbursts in Children and Adolescents. Curr Psychiatry Rep 24, 213–226 (2022). https://doi.org/10.1007/s11920-022-01325-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-022-01325-4

Keywords

Navigation