The TSCC and TSCYC screening forms allow you to quickly screen children for symptoms of trauma. Both forms are now available through PARiConnect- PAR’s online assessment platform. Learn more at parinc.com.
Hey, welcome back, everybody. Thank you as always for tuning in today. I think you are really in for a treat with the episode today, especially if you work with kids and especially if you have ever worked with kids who have some significant irritability and explosive behavior, and you found yourselves unsure how to work with those kids or diagnose [00:01:00] those kids or treat those kids.
So my guest today is Dr. Melissa Brotman. She leads the Neuroscience and Novel Therapeutics Unit (NNT) in the Emotion and Development Branch at the National Institute of Mental Health (NIMH) Intramural Research Program (IRP)
Dr. Brotman received her Ph.D. in clinical psychology from the University of Pennsylvania, where she specialized in cognitive behavioral therapy for mood and anxiety disorders. Her translational research integrates basic and clinical approaches to the study of mood disorders in kids and adolescents. Specifically, she uses affective neuroscience techniques to understand the brain-based mechanisms underlying severe irritability in youth and that leverages that pathophysiological knowledge to guide the development of novel targeted interventions.
So we talk about all of those things during the episode today. The framework is really how to conceptualize and treat these kids with [00:02:00] significant irritability and explosive behavior.
So we talk about irritability as a construct and how that relates to anxiety and depression. We talk about differentiating irritable kids from bipolar kids. We talk about Melissa’s somewhat novel treatment approach of using exposure therapy to work with irritability and anger. And toward the end, we dip into the uses of technology and things like ecological momentary assessment and using apps to assess mood and functioning in real-time, and several things along those lines.
So, this is just packed with fantastic information. Melissa is very knowledgeable and easy to interview guest. So I think there’s a lot to take away here.
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All right. Let’s transition to my in-depth conversation with Dr. Melissa Brotman.
Hey, Melissa, welcome to the podcast.[00:04:00]
Dr. Melissa: Thanks so much for having me.
Dr. Sharp: Yeah, I think I am more excited about talking with you than I have been with many of the guests over the last few months. No offense to any of the other guests, but the work that you were doing was just endlessly fascinating to me personally and professionally. And so, I am just so grateful that you agreed to come on and give some of your time here. So thank you so much again.
Dr. Melissa: Absolutely. I have been looking forward to it.
Dr. Sharp: Good. Well, let’s get right into it. I always like to ask why this work is important to you. Of everything that you could do in this field, why this?
Dr. Melissa: Irritability and temper outbursts, it’s interesting. In children, it’s one of the most common reasons kids are brought in for psychiatric care. And yet they’re kind of ontologically lost. So, when a kid presents with irritability[00:05:00] and temper outbursts, if you think back over the field, they could be diagnosed with many different things. And so bringing those symptoms together and seeing the extent to which they’re really impairing kids in a population and knowing how many treatments are out there to help these symptoms really has driven me to want to develop treatments for them.
Dr. Sharp: Yeah. I think this is such an interesting question and topic because the history of working with and conceptualizing these kids has been a winding one, right? And we’ve gone a few different directions to arrive at the place we’re at now. So could you provide a little context and just walk us through the history of how we have diagnosed or conceptualized these kids over the past two decades?
Dr. Melissa: Yes, it’s really interesting. So, if you were to think back to the 90s, children who presented with [00:06:00] acute temper outbursts and hyperarousal symptoms such as increased motor activity, pressured speech, a lot of times were conceptualized as having a pediatric form of bipolar disorder. However, if you think about bipolar disorder and its classic presentations, its episodes of mania and depression, and where these kids with irritability were classically presenting with irritability and hyperarousal symptoms.
So what we did at the NIMH, under definitely leaving loft is, we actually recruited kids who had classic episodic bipolar disorder and compared them to kids who were being diagnosed with bipolar disorder in the community that, in fact, were presenting with chronic irritability and hyperarousal symptoms.
And we did a series of studies to see if longitudinally as adults they had similar different presentations pathophysiologically [00:07:00] from brain-based mechanisms that were similar or different. And what the disorders were in the parents of these kids. And they were very, very different.
The kids who presented with classic episodic bipolar disorder ultimately as adults presented with bipolar disorder. Their parents were more likely to have bipolar disorder. And pathophysiologically, they were very different from kids with chronic irritability. Whereas the chronic irritability was more likely to develop into unipolar disorder or anxiety and their parents were more likely to have a unipolar depressive disorder or anxiety.
Dr. Sharp: Yeah. This is one of those things that was just kind of earth-shattering to me. This is part of my professional interests because I went to grad school, I started grad school in 2003. So it was I think toward the tail end of that, I mean, we were diagnosing [00:08:00] a lot of kids with pediatric bipolar, right?
And so by the time the DSM-5 came out, and I think that was with the advent of disruptive mood dysregulation disorder and digging into all that literature, which came from y’all, it’s so cool that I’m getting to talk to you now all these years later, it’s like, Whoa, this is a major paradigm shift from what I learned in grad school. And that’s always an interesting experience just as a professional, right? So kind of go a different path than what we learned or were taught.
Dr. Melissa: Yeah. It’s even been interesting to see the referrals over time. Whereas in the beginning, every child that we saw was referred to us with bipolar disorder. And now, the referrals are different. The kids are being diagnosed with disruptive mood dysregulation disorder based on some of that work.
Dr. Sharp: Right. So can you talk a little bit about just what you mean? I want to dig in a little bit more. When you say irritability and[00:09:00] hyperarousal and or chronic irritability, can you qualify that a little bit? What are we looking at behaviorally and mood-wise?
Dr. Melissa: Yeah. So these are kids that… they’re two aspects of irritability that we think about. There’s the mood aspect that bumbling along and at any given moment you can tell they’re just about to snap, and then the actual temper outbursts or behavioral manifestations of anger.
So a lot of times with the mood, when we talk to parents, we hear them say, “I just have to walk on eggshells around my kid. Any little thing could elicit some anger response, being asked to brush her teeth or do his homework.” And so what we think about these kinds of behaviors you can see are currently more concrete manifestations of anger, like temper outbursts [00:10:00] and that mood which is bubbling underneath just about to get angry or demonstrate anger.
Dr. Sharp: Yeah. I see this in so many kids that I work with. I’m curious. I will get out of my depth I think pretty quickly, but there are folks that are pretty interested in this kind of thing. I mean, you’ve done a lot of work, and like you said, the pathophysiology of these disorders, right? So can you speak to that a bit and what’s going on pathophysiologically with these irritable kids versus what’s happening with bipolar kids?
Dr. Melissa: Yeah, it’s a really good question. And it’s also interesting in so far as overtime, the paradigms, what we’ve done to even study these kids has evolved so much. I would say at the highest level, what I’m most confident about is that the kids present differently. [00:11:00] So when they’re doing a task such as looking at an ambiguous space emotion, kids with bipolar disorder have certain presentation patterns in the amygdala and areas that regulate emotions, prefrontal cortex, whereas kids with chronic irritability or what we’re talking about as these DMDD kids actually tend to look a little more like these kids with anxiety. And that actually helps lead me into the treatment development work weekends.
Dr. Sharp: Yeah. I want to talk about that. I think we’re going to have plenty of time to talk about the treatment, because that is absolutely fascinating to me, the way that you’re coming at treating these kids. I do want to dive into this piece of the overlap with anxiety. So DMDD is a depressive disorder or at least it’s classified that way in the DSM, right? So can you talk more about the relationship [00:12:00] between irritability and anxiety and depression and how those all fit together?
Dr. Melissa: Yeah. So there are two different ways one can think about it. You can think about it from the perspective of DSM in a categorical way or more from a dimensional perspective. And speaking more from the dimensional perspective which resonates more with me personally, most of these kids that I see that have been diagnosed with disruptive mood dysregulation disorder also present with anxiety. So it’s more common than not that there is at least some anxiety.
And if you want to go categorical into more of a DSM-based conceptualization, 50% meet at least one anxiety disorder criteria, full DSM criteria, but the other [00:13:00] 50% they’re a symptom or two away. So, it’s not that they don’t have anxieties, they just don’t necessarily meet a full anxiety disorder clinical diagnosis. The most common ones I see generally are generalized anxiety disorder, separation anxiety, and social phobia. Those are the three most common anxiety disorders I see in these kids with high levels of irritability.
Dr. Sharp: Got you. So I don’t want to push you into something that doesn’t feel comfortable, but I do want to ask then, coming from this categorical perspective and classifying it as more of a depressive disorder, do you feel like that makes sense, or did we miss it there a little bit?
Dr. Melissa: That’s an interesting question. There’s been so much talk about it. I think [00:14:00] we’re right. I think fundamentally it is a mood disorder. And so the fact that it’s in the mood disorders, I think is right. There is this underlying irritable mood and then there are these behavioral manifestations of temper outbursts.
There’s also been a lot of debate as to whether or not there should be a specifier for ODD. And so is it more of a behavioral disorder as opposed to a mood disorder? And I think that depending on your lens of where you’re coming from, I could see arguments in many different ways. I think the most important thing is what’s the most effective treatment. And DSM is great for the purposes of which it was developed, but it doesn’t necessarily help us develop the most targeted mechanism-based treatment.
Dr. Sharp: I think that’s fair. Yeah. I have had several folks on [00:15:00] that I think are in the same boat as yourself in terms of the dimensional model being… I hope that’s the direction we’re headed. It just seems to capture things a lot more clearly and accurately.
Dr. Melissa: Yeah, I think both are good and they’re synergistic. It’s kind of […]. They just serve slightly different purposes. And from a research brain base pathophysiology perspective, dimensions lend themselves more to say insurance-based perspective where you need a category to get reimbursed.
Dr. Sharp: Of course. I’m glad that you brought up ODD. I wanted to ask about that for sure. Again, the way that I was taught is that ODD is a behavioral disorder. It’s environmentally influenced more than anything else. And uses that stand in contrast to some of these mood disorders. [00:16:00] I guess over the years, I’ve seen some stuff that says that there are pathophysiological differences with ODD. I don’t know how accurate that is, but how do you reconcile those two? Like where do you see ODD fitting into this picture with these irritable kids, these mood disordered anxiety-driven kiddos?
Dr. Melissa: Yeah. So when we’re doing our semi-structured diagnostic interview, the case is that the vast majority of kids would meet the criteria for ODD. Now, for DSM, it’s exclusionary. So you don’t necessarily count it twice because you’re double-dipping. But again, I think it’s more a consequence of the parsing of how to put symptoms together. I guess the question that I would want to answer is, well, if you see two kids and one is ODD and one’s DMDD, [00:17:00] what would you tell me as the difference you’d see? And what I would say is the DMDD kid is having that chronic irritable mood throughout, whereas the ODD it’s more reactive aggression or more of a temper outburst parts, whereas the child with DMDD actually has both that irritable mood baseline with these episodes of anger as well.
Dr. Sharp: Yeah. That fits for me. My follow-up question is then how do you assess that? Especially with parents, I find that parents have a really hard time with this question. Like when I say, would you call your kid chronically irritable, or are they always in a bad mood, or are they more easy going between the tantra? I’m curious how you approach that because that is something that I struggle with.
Dr. Melissa: So, it’s a really great question and a really important one[00:18:00] and actually one that both clinically and as a real researcher, we’ve been struggling with because, in many ways, one thing that I’ve found in working with these kids is that the parent and child report is often so divergent.
And so, just to jump into something slightly different, one way in which we’re trying to get at that is by doing something called Ecological Momentary Assessment (EMA) which is digital-based phenotyping and where we probe parents and kids multiple times throughout the day to get at how has the mood been since the last beat was their temper outbursts since the last beat?
And so what I have found in some ways, it’s the retrospective report in asking the parents or the child in looking back over the past week. How was his or her mood or how has it been generally? But if you look at it more [00:19:00] prospectively with real-time data, I think you get much more accurate information. And so, one of the ways that I am hoping to move our research is by not solely relying on parents and child reference reports.
Dr. Sharp: That would be amazing. Is that available mass market at this point?
Dr. Melissa: I developed two web-based systems. And right now we’re working on an app that we’re starting to launch in the clinic for research purposes. It’s one of these things that once we figure out all the details of it, it’s developed by the federal government owns it, so we could share it. But it’s not out there yet, but I have found that at least in working with these kids, being able to look at that real-time data makes you feel like you’re getting closer to the truth.
Dr. Sharp: Yeah. That’s[00:20:00] really intriguing. I feel like that’s the direction we’re headed. It’s like this stuff can’t happen fast enough, honestly.
I run into a lot of difficulties with these kids, again, just assessing these symptoms and those moods for a number of reasons. I mean, their parents will say, well, he’s or she or they is in a great mood until we ask them to do something they don’t want to do. And I’m like, “Well, okay. Is that chronically irritable or is that just not wanting to do your chores?” So that’s one situation.
Dr. Melissa: I think that really hits the nail on the head. So what I’m always looking for, and what’s really important for DMDD is that it’s in multiple domains. So, if I hear that the chronic irritability or temper outbursts are only occurring with parents, [00:21:00] but teachers and friends are saying, “Oh, lovely kids. I don’t know what you’re talking about.” or only in school, it makes you think, Oh, is there something going on that’s different?
So if it’s only in school, is there some type of learning problem that we need to address here that might be leading to emotion dysregulation? if it’s only at home, is there some type of parent-child intervention that might be more appropriate? So, what I’m looking for are these irritability and temper outbursts that are pervasive across multiple domains and causing impairment in multiple domains.
Dr. Sharp: Right. Yeah. You’re anticipating my question. I feel like I see a lot of those kids too, where it’s only happening at home, not at school, not really anywhere else. But otherwise, it seems pretty compelling. So I appreciate you talking through that a little bit.
Let’s see. I wanted to ask [00:22:00] about the self-critical piece as well. And maybe getting at that mood component. The way that I’ve conceptualized these kids over the years, maybe this is that touch of depression that comes into it is that, there is often a critical nature to it as well, like that they can get down on themselves.
They can just be negative and find the negative in everything. They default to a negative appraisal or critical nature. I don’t know, does that resonate with you at all, or am I completely off base? And you can be totally honest there.
Dr. Melissa: So I think it depends very much on the developmental stage. So what you’re describing sounds a little more like the adolescent-age kids that I see. But the typical kid I have in my mind that[00:23:00] I tend to work with is a little younger and the cognitive aspect of it and the conceptualizations seems a little murkier. So, it’s feeling grumpy and waking up grumpy and having these responses to even the most mundane requests. And that’s always there. And even if you’re to try to get at some type of cognition underneath it, it is hard, which is in fact why I often take a behavioral intervention approach with the kids.
Dr. Sharp: Yeah. I see what you mean. Gosh, as we talk through this, it’s winding itself up in my mind. And no matter how hard I try, it’s difficult to separate how much of this is like depression versus anxiety. [00:24:00] That seems like it makes such a big difference. Is this just depression with irritability or is it… anyway, I’m getting spun out a little bit.
Dr. Melissa: I think it’s really interesting. And I think it’s an interesting question on one hand. On the other hand, how would it influence one’s treatment? And so for me, what I think of, okay, well, `you’re targeting something specific and regardless of what stream is coming through, if the child’s having an adverse reaction to a limit being set or a request in some way, practicing doing that over and over again in session has been helpful, regardless of it from more of an anxiolytic type of stimuli of being separated from mom versus limiting set of having to go do something that he or she doesn’t want to do.
Dr. Sharp: Right.[00:25:00] I feel like the conversation is just steering over and over toward what do we do about it? What’s the treatment, right? So this message of yes, the etiology matters, of course. And it’s really, what do we do about it and how do we help these kiddos and their families?
So before we totally transition to this treatment approach with which I think is pretty novel, and it was really interesting to hear about during our pre podcast chat, is there anything else to say just about the nosology or how we conceptualize these kids? What’s happening in their brains that may be different than what we’ve historically thought about?
Dr. Melissa: I guess if I was to highlight one point, the biggest point being that chronic irritability[00:26:00] and temper outbursts are not a manifestation of pediatric bipolar disorder in the absence of these acute episodes. And particularly the pharmacological interventions for pediatric bipolar disorder are very different than what you would think of to treat a child who has more of a depressive mood or anxiety type presentation.
And so from that perspective, I think it does matter the nosology. I’m contradicting what I said a moment ago, but I think it depends on the differentiation of nosology that you’re thinking about. So bipolar disorders are very different than say unipolar or even anxiety from a pharmacological intervention perspective.
Dr. Sharp: Right. I know this is a whole other podcast episode and we don’t have to totally open this can of worms, but is [00:27:00] there anything else you could say even just briefly about differentiating these kids from pediatric bipolar kids?
Dr. Melissa: Yeah, so I would say if you’re thinking of pediatric bipolar disorder, the idea of an episode and that all the symptoms you’re seeing are clustering together over a period of time, and when I say time, we’re thinking of the magnitude of days here as opposed to hours or minutes. And I often very much look for changes in sleep and not needing sleep and still having tons of energy. Whereas the kids that I’m thinking about for DMDD, could have a very intense emotional reaction, but these other cluster B symptoms are not clustering together at a particular time frame [00:28:00] in an episodic way.
Dr. Sharp: Sure. That’s validating. That’s been my fallback as well is looking for these really discreet episodes as much as we can. And just pharmacologically speaking, I know you’re not a prescriber, of course, but you alluded to these differences in pharmacological treatment. So, can you say any more about that?
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All right. Let’s get back to the podcast.
Stay within your scope.
Dr. Melissa: So yeah, as a clinical psychologist, I hesitate to talk too much about pharmacology, but I’ve been involved in some research that has demonstrated that SSRIs and stimulants can be effective for kids with disruptive mood dysregulation disorder, and that’s work that Ken [00:30:00] Tobin spearheaded with Ellen[…].
And that was a double-blind randomized controlled trial. And so that really makes you think, well, that’s the exact opposite. A stimulus in an SSRI is exactly the opposite of what you might think is indicated for a child that’s actual pediatric bipolar disorder. And in fact, that combination was helpful to kids with chronic irritability. So in that sense, it really is very much a decision point. Does this child truly have episodic pediatric bipolar disorder or is it more of a continuous pattern of irritability?
Dr. Sharp: Right. Okay. Thanks for digging into that just a bit. Well, I think we’ve put it off long enough. I would love to talk with[00:31:00] you about the treatment approach that you are, I don’t know, would you say developing? Is this something that y’all have developed or is it something you’re piloting based on other’s work or what? I want to make sure to get the terminology right.
Dr. Melissa: Yeah. It’s interesting science in general, and even if you look back in time, it’s people who often come to ideas at the same time. And so as I was developing these ideas, I’ve found other pockets of people in the nation doing it as well. And it’s interesting that we came to some of these things at the exact same time in and of itself. So I wrote a manual and at the same time, I talked to other people that have aspects of what I’m doing in some of their manuals. So it makes you feel more confident in what you’re doing when you see other people you respect a lot doing similar approaches.[00:32:00]
Dr. Sharp: Well said. I think that’s a story with a CRISPR as well, that there were two folks who were like neck and neck and is basically just like racing to the patent office first or whatever. That’s really cool. So tell us about this? What is this treatment approach?
Dr. Melissa: Yeah. So as I mentioned after the work indicating that kids, DMDD is a presentation of kids and symptoms that is different from pediatric bipolar disorder. I started thinking, all right, well, so now we’ve identified these kids. But how can we treat them? What would be the go-to interventions for a child that has chronic irritability and temper outbursts? And if you think about it, you have your classic treatments for [00:33:00] anxiety disorders, you have your more classic treatments for depression, family interventions.
And as I was looking at the literature and of course, parent management training for a lot of the behavioral disorders and ODD, as I was looking, I was thinking, wow, well, I guess since this is a new diagnosis it’s not surprising that there’s nothing specifically indicated for DMDD for us to be doing.
And so, I at first was looking and seeing aspects of different treatments that we might be able to combine. And the more I thought about it and the more I thought about the pathophysiological similarities between anxiety and irritability, the more I thought might exposure to anger and irritability be an effective treatment. So similar to anxiety,[00:34:00] we think of anxiety and anger as being discreet, high arousal, negative valence states, and…
Dr. Sharp: Can I stop you just for a second? Can you explain that little phrase you just used? High arousal, negative valence? What exactly is it?
Dr. Melissa: Yeah, sure. So, if you were to think of emotions in at least two dimensions, X dimension, and a Y dimension, you can think of valence from negative valence to positive valence. So negative valence, sadness, anger, fear. Positive balance, happiness, and excitement.
And then arousal being from higher arousal to low arousal. So high arousal being amped up with energy. So the positive valence [00:35:00] high arousal, we’ll be excited. Whereas negative valence high arousal is anger, fear, negative valence low arousal like more depression.
And I kept coming back to the way in which anger and fear are similar. And they both are also elicited by a stimulus. So something happens or you anticipate something happening and it can lead to fear or anticipatory anxiety or you’re confronted with something and it makes you angry. And the more I thought about it, it all hearkens back to the evolutionary psychology of fight or flight that when presented with a threat, depending on how close[00:36:00] the threat is, one’s emotional behavioral response aligns with how close the threat is. So if the threat is far away, it makes sense to freeze or have an avoid response.
The bear is far away. You don’t want to be detected. You freeze the bear won’t see you. You move away. However, if that stimulus is right up in your face, your adaptive thing is to actually engage and fight with the stimulus. And the fact that threat responding is mediated by this highly evolutionarily conserved process and that it can lead to either a fear response or an anger response made me pause and think.[00:37:00] Well, we know that extinction which we engage in through exposure is effective for anxiety, might that also be effective to get rid of the anger that’s getting in the way of our everyday life?
Dr. Sharp: It sounds logical to me. That’s a great connection. Yeah. I appreciate you taking the time to explain all of that. When you laid out that way, it’s like, duh, we should be targeting this. We should’ve been coming at it this way for a long time.
Dr. Melissa: Well, but my fear at first was, and I got into it very slowly because I wasn’t sure if by having kids just like invoking anxiety in a child who has an anxiety disorder to have them habituate to the[00:38:00] feared stimulus, you can also sensitize and make the symptoms worse. And so in the beginning, I was very worried that doing this one could actually make the anger worse. And so over years and years, I slowly dipped my toe into it. And the more I started working with the kids and really doing it slowly and carefully, it did indeed seem that it is an effective treatment.
Dr. Sharp: That’s amazing. Can you describe it in more detail? What does this actually look like in real life?
Dr. Melissa: Yeah. One of the most common questions I asked is what is anger exposure. I can imagine a fear of exposure. It’s one of the greatest spiders, you look at the picture of the spider, you watch a video with a spider, you encounter the spider.
So for the kids I work with, first, just like [00:39:00] I would do with anxiety, we generate an anger hierarchy. So things that make them a little bit angry, all the way to very angry. And we fill out what we call temperature ratings. And then what we do is actually engage in an exposure.
So the classic ones, there was one child I worked with who got very angry when her parents asked her to do household chores. And the specific household chore that really got her upset was sorting the laundry and folding the laundry. And so what I did is I had mom bringing bags of the same laundry into the session. And what we did was the first exposure to just pouring the bag of laundry out and looking at it on the table and getting anger ratings.
And plotting the curve[00:40:00] of the anger rating and I’m doing that over and over again, then taking soccer too and folding it.
And we did this over and over and over again within a session and between sessions such that by the end of our 12 weeks together, she knew mom would be bringing it along to pour it out. She would fold it and sort it, and then we’d get on to the rest of our session. And it did transfer to home. She said that she had practiced in session dealing with that anger response to being asked to do it. And I would even act out, me walking in the room and asking her to do it like a parent might.
The most common exposure, and I think no one will be surprised to hear this, is asking a child to stop playing a video game. And so the classic one is, having a child bring in[00:41:00] years ago, it was their full gaming system. Now it’s just a phone or an iPad and having them play video games. And even how far they get into the game, are there points of the game or their level of the game and having them stop at certain points in time during the game and deal with having their emotional response and having to stop playing the game and practicing stopping is a very effective exposure. And if we want to up the ante, we have them start doing homework afterward, like something, a less preferred activity.
Dr. Sharp: Wow. Yeah. I suppose you can manipulate the activities as much as you want.
Dr. Melissa: Make it a compound exposure.
Dr. Sharp: A compound exposure. There you go. Yeah. You’ve got my mind spinning. I’m thinking of my own kids as well, of course, as we talk through this. But that’s part of my interest too. I think I mentioned in our[00:42:00] pre-podcast chat that our son is certainly in this ballpark. I don’t know that it’s maybe diagnosable, that’s always part of a parent psychologist, but very reactive, very critical. So this is very relevant for me. I’m curious about the process. So I’m guessing or assuming that you’re teaching coping skills as well, like a classic exposure. Is that right?
Dr. Melissa: That’s exactly right. So I’m one of the… a lot of the kids I work with, I find have some difficulty articulating their feelings. And so what I’ve used a lot, particularly with the younger kids. And when I say younger, I’m thinking 8, 9, 10 is drawing. So I’m having them articulate where they’re feeling the anger in their body. They’re drawing where they feel the anger in their body. And really being able to[00:43:00] label it and focus on it and know that over the course of time, by sliding their anger ratings, they learn both cognitively and behaviorally that the anger always comes down.
Dr. Sharp: Yeah. I’m just pausing, that seems like a powerful lesson for kids to be able to learn.
Dr. Melissa: Yeah. And something about plotting it, as we’re doing exposures, as I ask for a temperature rating every minute. And so we literally plot it out. And so we can in a very concrete way, see the changes in the arc, how steep this slope is, how high it goes, that over time, that first time looking at that bag of laundry got you at an eight and now only a week and a half later, looking at[00:44:00] that laundry gets you at a three.
And look, you’re the one who said it, you’re the expert here. We can look at that. And I think seeing the fact that the temperature goes up, that the anger will go up, but it always comes down and that is getting better over time is a very salient feature for our kids in terms of having a sense of mastery or control over this aspect of themselves that’s really causing them a lot of distress and problems.
Dr. Sharp: Right. I think that a common tenant of these approaches is like kids, it’s not good for kids. Like kids aren’t happy during these times. They aren’t enjoying it by any means. It feels out of control and it feels scary. So giving them some mastery. So are you saying, just to be clear, and this might be a dumb question, but are you framing the actual plotting of the anger level as an intervention,[00:45:00] like as a coping skill in and out of itself almost like mindfulness or in some way?
Dr. Melissa: Yeah, I think having this concrete visualization of this emotional experience that can be bifurcated from the South, that’s kind of distance in some way, gives a sense of control over it. Like yes, this anger is something, Ego-dystonic. Something I don’t want. Something that I want to change. And we can fight it. And we can work on it. And we can see how to deal with it in real-time.
And I’m saying the ego-dystonic is actually a pretty relevant feature and so far as when I’m talking with the kids about that anger or temper outbursts that we want to work on, I have them guide me [00:46:00] as to the way in which their anger is getting in the way of their life. So we talk about how just like fear, just like all emotions, you need to have fear sometimes. What will happen if you were afraid? You might get hurt.
Well, what would happen if you never got angry? Well, you might get taken advantage of, or your brother or sister might always get that last scoop of ice cream. And so what we start out with is, okay, what are the ways in which anger is working for you? And we write all those down.
And then we say, okay, what are the ways in which anger is causing problems? And we write those down. And I say, okay, we’re only going to work on these ways in which the anger is causing you problems. And so we were on the same team in terms of this is an aspect of the child that they don’t want to be experiencing either. It’s less of[00:47:00] your parents don’t like it or teachers don’t like it. It’s what is causing you distress.
Dr. Sharp: Right. I would imagine that process in and of itself is pretty powerful just to give kids some agency over their feelings and their thoughts. And aluminate some of those internal processes that maybe were pretty obscured before that.
Dr. Melissa: Yeah. And sometimes they’ll say, well, yeah, temper outbursts work for me. Having a temper tantrum worked when my mom asked me to unload the dishwasher and I haven’t had to do it in two years. And so we laugh and say, Hmm. But at least it’s putting everything on the table of where things stand. And then talking about how much do you want to change this? Like a classic motivational interviewing and a readiness ruler.
Dr. Sharp: Yeah. I get that. Now you mentioned [00:48:00] that age range a little bit ago. What’s the lower limit for an intervention like this, as far as y’all been able to determine.
Dr. Melissa: The youngest kids I worked with are 8 years old. Say around8 years old and we go all the way up to 17. And so that’s a pretty big age range. I would say having now done this treatment for a period of time, we could probably extend it down to younger kids. I don’t know about getting into older kids, I mean, young adults, it feels a bit different particularly because we have a pretty solid parent management training piece, which is plastic TMT. But I could imagine going a bit younger because we[00:49:00] do a lot of the intervention based on non-verbal communication, acting, drawing, ways in which I could imagine works with younger kids.
Dr. Sharp: I see. Yeah. I have two questions just to close the loop on any other coping skills that you might be teaching the kids during this time. And I guess that’s a question too. Like, are you maybe beating a dead horse here, but are you actively teaching coping skills to have them wrangle their anger downward, like purposefully decrease their anger level? Or is it just, again, that mindfulness piece of noticing where they’re at as the intervention more than anything else?
Dr. Melissa: I would say it’s more of the latter[00:50:00] than the former, but I would tweak it in so far as that you can feel anger without having a behavioral response of breaking something or wanting to quench your thirst and do somethings and have this kind of motor response.
So a lot of the kids that I’m working with, they get angry then they feel like they need to have this moat towards release. And so it’s tolerating and noticing that they may feel hot in their hands or that they want to break something or move, but they don’t necessarily have to.
And that they can, that doing that motoric response doesn’t release the emotion or make it go away that it can go away on its own. And so the next time you get upset, you don’t need to throw your iPad, you know that you can tolerate the emotion in and of itself without having some[00:51:00] type of motor action. And that the motor action doesn’t really make it go away.
Dr. Sharp: Yeah. I love that. I’m thinking, we need this as adults. This is basically, I mean, it sounds like mindfulness. I don’t know if you would describe it that way, but it’s just like riding the wave of the urge or the emotion or whatever you want to call it.
Dr. Melissa: Yeah. It’s interesting. When I was talking about how different people come to this in different ways, one of my friends said, Oh, she developed essentially a DVT for DMDD. And when we were talking, we realized that we were basically doing the exact same thing in session, but we just were calling it different things. And yes, I took it from a behavioral perspective and used this behavioral language and she would say, well, I do the exact same thing, but I call it this. And we were chuckling.
Dr. Sharp: That’s great, many paths to the top of the mountain, right. As long as it works. [00:52:00] So I did want to ask you, you briefly touched on this, but the parent component of all this, is there a parent education piece? Is there a parent support piece? How does that look like?
Dr. Melissa: The parent management piece I would say we borrowed very heavily from the vast literature out there of just classic training of reinforcing positive behavior, actively ignoring non-dangerous behavior that you don’t want to be seen more of classic reinforcement schedules and practicing with parents how to do these things in sessions.
So even simple aspects of praise, we’ll practice behaviourally in sessions having a parent praise the child for something that they liked [00:53:00] seeing all her actively ignore the [00:47:00] tapping of the pen during the session if the kids moving around a lot and it’s not really causing any distress to anyone. And so I would say, it’s very much classic parent management training basics from Barkley back in the day that we just adopted to tweak to our specific populations.
Dr. Sharp: I got you. So this may be the wrong question to ask you given how firmly rooted it seems like you are in behaviorism and parent management, but do you see any role for some of the more, I don’t know if you’d call them collaborative approaches or some of that interpersonal neurobiology stuff, like the Dan Siegel stuff or like Ross Green and the collaborative and proactive solutions. Like, do you see any place for that in working[00:54:00] with these kids? And if so, what’s it like? If not, that’s still okay.
Dr. Melissa: Yeah, I love Ross Green’s book. I mean, I definitely agree with all those pieces. I would say for me as a clinical researcher, it’s a manualized treatment, and so I’m limited to what we can do in the protocol. And so what I might do in the community having more time, definitely, I think that would be phenomenally great. But from the perspective of limited time and resources and what we’re doing in our research protocol, we don’t have that kind of time to get into some of those higher-level explanations for parents.
Dr. Sharp: [00:55:00]That totally makes sense. I appreciate you articulating them. What else? Oh, I did want to ask you about the work that you’re doing. You mentioned it way back, but with the EMA stuff. And I know that you are interested in app development and some of this ecological assessment stuff. Can you talk about that a little?
Dr. Melissa: Absolutely. I love that as well. I think there are so many opportunities out there. Technology is moving so quickly. And as a psychologist, as a researcher, I want to be able to think proactively about ways in which we can leverage technology to get the best information for interventions, for assessment. And ultimately as more and more people have digital devices and there are [00:56:00] other ways that we could be monitoring and gathering data and recording data, I think that there’s very much a window for clinical psychologists to be getting more information than we currently do.
I think back in the day when I was trained and had an activity schedule, dysfunctional thought records when people would be writing things at home or in, I remember even saying I want to pretend like I’m on your shoulder and see what your mood went like over the course of the day.
So we can see when your mood dips or when your mood doesn’t fit. And that now we actually have that capability. People are holding phones. People are wearing Apple watches and devices. There are ways in which we can get both passive data. So things like arousal, heart rate, variability movement, all the way to these other assessments,[00:57:00] such as mood ratings that you get multiple times throughout the day.
And one of the ideas I’ve been playing with a little is developing an app that can probe some type of specific psychological process. So like inhibitory control, motor inhibition, and seeing how that might change as a function of a child’s mood. And are there ways in which we could ultimately, and again, this is in the next 10 years, I think this would be awesome if we could do this, but a way in which we could though similar to other medical disorders seizure or migraine, there are a certain constellation of variables that predict with some degree of accuracy that someone might get a migraine in the next half hour or have a seizure?[00:58:00] Their seizure threshold is lower. That we could be accumulating data based on sleep, based on movement, based on performance on various tasks that ultimately could have us have some degree of predicting the likelihood that a child would have an acute temper outburst or be very irritable or have a panic attack within some period of time.
And that there could be some type of closed-loop system whereby as a provider, we could be gathering this information and actually intervening such that adjusted time intervention before the event actually occurs, before the child has that very intense anger outbursts or a depressive episode.
Dr. Sharp: Something like that would be a dream for clinicians, right? I mean, this is[00:59:00] the kind of stuff I literally dream about but don’t have the resources or time to really make it happen, but you’re living in that world. And it sounds like the research or the development is moving in that direction. Is that fair?
Dr. Melissa: Slowly but surely. So I have one foot firmly planted in our imaging and understanding pathophysiology and understanding the way in which it evolved from other brain-based models, but then I have another foot dancing into this other arena whereby I’m thinking if we can be collecting data and let’s just see what information we can gather.
And so what I’ve been doing, and particularly during the pandemic where we’ve been remote and we haven’t been able to see kids on campus, in the same way, is pushing apps and trying to [01:00:00] gather this data and see if performance is relating to any emotions over the course of time. And at least seeing if there’s any type of signal there that’s worth pursuing.
Dr. Sharp: Sure. Is there anything out there at least at this point that you feel it’s worth looking at in terms of mood tracking apps or even biometric data that is worth measuring? Are we even there yet?
Dr. Melissa: I think we certainly have the technology. I think the way in which we need to be hesitant is what question are we answering? And so I think that the bigger issue is we have a lot of these metrics and devices but we need to spend a little more time seeing what they’re actually giving us and what we can use and not to jump [01:01:00] too far ahead of the data and saying, Oh, we can now predict ADHD or predict something. So, I think it’s threading the needle of using the information we have, and while I’m enthusiastic about it, not jumping into it too quickly and going too fast and faster than the data.
Dr. Sharp: I appreciate you highlighting that. I think that’s always the danger, right? Like we get very excited about the technology and the data we can collect, but it’s then what do we do with it? I think there’s a lot of leaping to conclusions.
Dr. Melissa: Yeah. And so for me, I’m just trying to do it on an individual basis to see one at a time almost idiographic with what can we learn? And then I’m expanding slowly.
Dr. Sharp: Yeah. I like that. The measure of caution goes a long way. Well, this has been a great conversation. I feel like I could ask you a ton more questions about technology [01:02:00] and mood and all sorts of things, but we can leave it here for now. So, thanks so much for coming on and talking through these things.
Dr. Melissa: Thanks so much for having me. This has been a lot of fun.
Dr. Sharp: Good. Well, if I haven’t scared you away, maybe there are around two in the future depending on how your work develops.
Dr. Melissa: Absolutely.
Dr. Sharp: Okay, everyone. Thank you so much for listening today. This is a good one. I took a lot of notes myself, and I hope that you are taking away quite a bit of information as well.
Like I mentioned at the beginning, if you’re an advanced practice owner, or hope to be an advanced practice owner, you can get some information about the Advanced Practice Mastermind Group which is starting on June 10th. It’s in about a month, I think. And you can get more information here at thetestingpsychologists.com/advanced. We have a few spots left. And I would love to help you take your practice to the next level.
All right. That is it for today.[01:03:00] Hope everyone is doing well, enjoying some spring weather, and otherwise hanging in there. Take care. And I’ll talk to you next time.
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