Anger, Externalizing Behavior, Irritability, Suicidal Behavior, Suicidal Ideation
Conditions
Keywords
Cognitive Behavioral Therapy, Irritability, Preteen Children, Suicidal Ideation, Suicidal Behavior
Brief summary
This pilot study evaluated whether cognitive behavioral therapy for anger and aggression, added to treatment as usual, was associated with reductions in irritability and suicidal ideation in preteen children with externalizing disorders. Children aged 8 to 12 years who were referred to an outpatient child psychiatry clinic for irritability, anger outbursts, or reactive aggression were assigned to CBT-AA plus treatment as usual or treatment as usual alone. The intervention included individual child sessions focused on emotion regulation, problem-solving, and social skills, with parent guidance sessions. Irritability and suicidal ideation were assessed at baseline, during treatment, at the end of treatment, and at follow-up.
Detailed description
This was a partially randomized, pragmatic pilot study conducted in a child psychiatric outpatient clinic at Geha Mental Health Center in Israel. The study included children aged 8 to 12 years with externalizing disorders, including ADHD, oppositional defiant disorder, intermittent explosive disorder, disruptive mood dysregulation disorder, or conduct disorder, who were referred because of clinically significant irritability and/or reactive aggression. Participants were assigned to cognitive behavioral therapy for anger and aggression plus treatment as usual or to treatment as usual alone. During the initial treatment cycle, allocation was conducted using a computerized randomization procedure with sequentially numbered, sealed opaque envelopes and stratification by recent suicidal ideation or suicidal behavior. In later treatment cycles, assignment was constrained by therapist availability and scheduling within the outpatient service. For these later assignments, participants were allocated according to treatment capacity and order of referral rather than by participant clinical characteristics. CBT-AA was delivered as an individual, in-person, protocol-based treatment. The intervention focused on three main domains: emotion regulation, social problem-solving, and social skills. Treatment as usual consisted of routine psychiatric consultation, pharmacological treatment when indicated, and non-behavioral psychosocial interventions available through the clinic. The primary outcome was irritability, assessed with the Irritability and Dysregulation of Emotions Questionnaire-13 and the Affective Reactivity Index. Secondary outcomes included suicidal ideation and suicidal behavior assessed using the Columbia-Suicide Severity Rating Scale. Assessments were conducted at baseline, after treatment modules, at the end of treatment, and during follow-up. The study was approved by the Institutional Helsinki Committee of Geha Mental Health Center. This record is being submitted retrospectively.
Interventions
BEHAVIORALCognitive Behavioral Therapy for Anger and Aggression
Protocol-based individual cognitive behavioral therapy for anger and aggression delivered in person in an outpatient child psychiatry clinic. The intervention included three treatment modules: emotion regulation, social problem-solving, and social skills. The emotion regulation module focused on recognizing anger triggers, monitoring emotional intensity, labeling emotions, identifying bodily signs of anger, and using strategies to reduce physiological arousal. The social problem-solving module focused on interpreting social cues, considering other perspectives, generating alternative responses, and managing the effect of anger on thinking and decision-making. The social skills module focused on assertiveness, prosocial responses to interpersonal conflict, role-play, guided practice, and generalization of skills to daily situations. Parent guidance sessions were included, and parents were briefed by therapists during the treatment process. The intervention was delivered in addition to t
BEHAVIORALTreatment as Usual (TAU)
Routine outpatient psychiatric care, including psychiatric consultation, pharmacological treatment when indicated, and non-behavioral psychosocial interventions available through the clinic.
Sponsors
Geha Mental Health Center
Chief Scientist, The Israel Ministry of Science
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Masking description
None (Open Label). Participants and research staff were not blinded to treatment allocation. Therapists were not involved in outcome measurement. Outcomes were based primarily on parent- and child-report questionnaires, with suicidality assessed by research clinicians.
Intervention model description
Participants were assigned to one of two parallel treatment arms: cognitive behavioral therapy for anger and aggression plus treatment as usual, or treatment as usual alone. Initial allocation used a computerized randomization procedure with sequentially numbered, sealed opaque envelopes. Because of pragmatic outpatient clinic constraints, later assignments were determined by treatment capacity and order of referral rather than by participant clinical characteristics.
Eligibility
Sex/Gender
ALL
Age
8 Years to 12 Years
Healthy volunteers
No
Inclusion criteria
* Child age 8 to 12 years * Parent or guardian able to read and write in Hebrew * Receiving care in the Geha outpatient child and adolescent clinics * Clinical diagnosis of ADHD, oppositional defiant disorder, intermittent explosive disorder, disruptive mood dysregulation disorder, or conduct disorder * Irritability and/or reactive aggression as the reason for treatment seeking
Exclusion criteria
* Psychotic disorder or bipolar disorder * Substance use * Autism spectrum disorder * IQ score less than 75 or clinical diagnosis of intellectual disability * Immediate suicide risk requiring hospitalization as determined by the referring clinician
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Parent-Reported Irritability Measured by the Irritability and Dysregulation of Emotions Questionnaire-13 | Baseline; end of Module 1, approximately Weeks 6 to 9; end of Module 2, approximately Weeks 10 to 15; end of Module 3/treatment completion, approximately Weeks 16 to 23; 1 month after treatment completion; and 3 months after treatment completion. | Irritability was assessed using the Irritability and Dysregulation of Emotions Questionnaire-13. Parent-report and child-report versions were administered. Items are rated on a 7-point Likert scale from -3 to +3, and summary scores were calculated as the mean of completed items. Higher scores indicate greater irritability. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Irritability Measured by the Affective Reactivity Index | Baseline; end of treatment, approximately Weeks 16 to 23; 1 month after treatment completion; and 3 months after treatment completion. | Irritability was assessed using the Affective Reactivity Index. Parent-report and child-report versions were administered. Items are rated on a 3-point Likert scale, and summary scores were calculated as the mean of completed items. Higher scores indicate greater irritability. |
| Change in Suicidal Ideation Severity Measured by the Columbia-Suicide Severity Rating Scale | Baseline; end of Module 1, approximately Weeks 6 to 9; end of Module 2, approximately Weeks 10 to 15; end of Module 3/treatment completion, approximately Weeks 16 to 23; 1 month after treatment completion; and 3 months after treatment completion. | Suicidal ideation severity was assessed for the relevant C-SSRS reference period at each assessment. The primary suicidal ideation analysis used baseline, end of treatment, 1-month follow-up, and 3-month follow-up assessments. |
| Occurrence of Suicidal Behavior Measured by the Columbia-Suicide Severity Rating Scale | Baseline; end of Module 1, approximately Weeks 6 to 9; end of Module 2, approximately Weeks 10 to 15; end of Module 3/treatment completion, approximately Weeks 16 to 23; 1 month after treatment completion; and 3 months after treatment completion. | Suicidal behavior was assessed using the Columbia-Suicide Severity Rating Scale. Suicidal behavior was coded as present if a suicide attempt, interrupted attempt, or aborted attempt was reported by either the parent or the child during the assessment period. |
Countries
Israel
Contacts
PRINCIPAL_INVESTIGATORTomer Levy, MD
Geha Mental Health Center
Outcome results
None listed