The Use of Standard Parenting Management Training in Addressing Disruptive Mood Dysregulation Disorder: A Pilot Study

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https://doi.org/10.1007/s10879-021-09489-5 ORIGINAL PAPER

The Use of Standard Parenting Management Training in Addressing Disruptive Mood Dysregulation Disorder: A Pilot Study

Gary Byrne¹ · Graham Connon²

Accepted: 27 January 2021 / Published online: 9 February 2021

Abstract

Parent management training has demonstrated effectiveness in the treatment of child behavioural issues and associated conduct difficulties. Anger, aggression, and irritability are common symptoms amongst children presenting with disruptive mood dysregulation disorder. Currently, there are no well-established evidence-based interventions for children presenting with symptoms of disruptive mood dysregulation disorder. This pilot study aims to assess if a standard, well-established, parent management training program (group Triple P) may be effective in addressing disruptive mood dysregulation disorder symptoms. Thirteen parents of children who presented with disruptive mood dysregulation disorder or subthreshold symptoms completed the Triple P behavioural management program (Level 4). Post-treatment, parents reported no significant change on childhood irritability. However, parents noted significant improvement on child overt aggression, behavioural difficulties and an increase in child pro-social behaviours. Despite the many limitations inherent in this pilot study, results suggest that standard parent management training may be useful in addressing overt aggression but not irritability.

Keywords Disruptive mood dysregulation disorder · Parent management training · Irritability · Overt aggression · Triple P

Introduction

Chronic and severe paediatric irritability is a common presenting problem in clinical services and one that is associated with long-term adverse outcomes (Stringaris and Taylor 2015). Irritability is defined as a low threshold for experiencing anger in response to frustration. Irritability has been found to be associated with both mood and anxiety disorders. Findings indicate that up to half of youth who meet criteria for severe mood difficulties have a comorbid anxiety disorder (Dickstein et al. 2005) and that the presence of such severe mood dysregulation in childhood predicted later depression in adulthood more so than an actual episode of childhood depression (Brotman et al. 2006). Specifically, disruptive mood dysregulation disorder has been reported to co-occur with another behavioural and emotional disorder in 65% to 90% of cases (Brotman et al. 2006; Dougherty

et al. 2014). The growing clinical significance of irritability is evident with the inclusion of the diagnosis of disruptive mood dysregulation disorder in the DSM-5 (APA 2013).

Currently there are no gold-standard psychological treatments for disruptive mood dysregulation disorder and the evidence base remains sparse (Brotman et al. 2017; Strin- garis et al. 2018). This is in spite of a number of well-established treatments for comorbid presentations that include irritability such as oppositional defiant disorder and conduct disorder (Furlong et al. 2013). Interventions for disruptive mood dysregulation disorder can fall within two categories;

interventions focused on both parenting and childhood difficulties, and other interventions working solely with children. Regarding child-focused interventions, programs that fall under the cognitive behavioural therapy (CBT) rubric such as CBT for Anger and Aggression in Children (Suk- hodolsky and Scahill 2012) have been developed to address disruptive mood dysregulation. Results from these programs are promising, suggesting that such interventions can help reduce symptoms of disruptive mood dysregualtion disorder and that standardised treatments can be effective in reducing relative symptoms such as irritability (Evans et al. 2020).

Other treatment programs such as Exposure-based CBT for irritability (Kircanski et al. 2018), the Unified Protocol for

* Gary Byrne gary.byrne@hse.ie

1 Primary Care Psychology Services, Health Service Executive, Dublin 14, Ireland

2 Psychology Department, Health Service Executive, Dublin 15, Ireland

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Transdiagnostic of Emotional Disorders in Children (UP-C) for paediatric irritability (Hawks et al. 2020) and dialecti- cal behaviour therapy for children (DBT-C; Perepletchik- ova et al. 2017) include both parent and child curriculum in the management of challenging behaviour, temper, and irritability.

Parent management training is an effective intervention in reducing childhood behavioural problems and associated difficulties (Furlong et al. 2013). However, the research to date has been limited regarding the effectiveness of such approaches for symptoms of irritability, temper, and aggression associated with disruptive mood dysregulation disorder. Only a limited number of studies to date have looked at the use of parent management training in the treatment of symptoms such as irritability and most of these studies included parent management training as part of a wider treatment package. For example, Waxmonsky et al. (2016) utilised a treatment that combined CBT, social cognitive programs, and parent management training in addressing child mood difficulties and attention deficit hyperactivity disorder (ADHD). Findings indicated the intervention was successful in alleviating irritability but not mood symptoms amongst a cohort of youth presenting with both ADHD and severe mood dysregulation.

Research into treatments for irritability has indicated that standardised treatment approaches may be effective.

Evans et al. (2020) found that a modular, transdiagnostic, behavioural/cognitive-behavioural intervention (MATCH) that included a parent behavioural management component was more effective in reducing severe child irritability than participants assigned to standardised treatment and usual care. However to date, there has been little research assess- ing how standard parent management training, without the use of other child focused-interventions, may be an appro- priate first-line treatment for children presenting with overt aggression and irritability. The use of a parent-only approach for disruptive mood dysregulation disorder may be a useful intervention in a stepped care model, especially for children who may be particularly reticent to interact or engage therapeutically. An effective first-line treatment may also be useful for children requiring less intensive treatment that can be provided by other interventions (Perepletchikova et al.

2017). In addition, NICE guidelines indicate that parent management training is the optimal first-choice treatment for children under 12 presenting with externalizing behavioural difficulties and this may be a similar treatment consideration for disruptive mood dysregulation disorder.

The Triple P behavioural management programme uses a range of behavioural techniques and strategies to help parents effectively deal with and reduce child behavioural difficulties. The program has been shown to be effective for a broad range of externalizing child behavioural difficulties, including oppositional and defiant behaviour and common

co-morbid difficulties such as attention and hyperactivity issues (Sanders et al. 2014; Bor et al. 2002). However to data, the Triple P has not been used specifically for child populations presenting with disruptive mood dysregulation disorder and high levels of irritability. The need for such a pilot study is clear given the lack of more rigorously controlled trials addressing disruptive mood dysregulation disorder. It is hoped that this pilot study will provide a range of important functions (Van Teijlingen and Hundley 2002) in specifying if parent management training could be useful as a sole treatment as well as providing insights for further research. The current pilot study is one of the first to use a standard parent management training to gauge if such approaches are effective in reducing overt aggression and irritability amongst children presenting with disruptive mood dysregulation disorder or sub-threshold symptoms.

Method

The current pilot study used a pre-post group treatment design. All children were referred into child psychology primary care services in south Dublin in the Republic of Ireland due to externalizing behaviours. Parents were contacted to enquire about their interest in attending the program. Ethical approval was received from the local ethics committee. Par- ents completed the consent form a number of weeks before the groups started. All parents completed the questionnaire battery in-person just before the beginning of the initial session and post-measures were completed following the end of the group. All data was analysed using PSPP software (GNU Project 2015).

Participants

Eligible participants were parents of children aged between 6 and 12 demonstrating irritability, aggression, and temper outbursts. Twenty parents were screened for potential suit- ability for the program. They were referred into the Primary Care Service and the main difficulties on referral related to externalizing behavioural difficulties. Inclusion criteria were purposefully broad. Exclusion criteria included a diagnosis of autism spectrum disorder and parents not being in a position to attend the programme. Thirteen parents were included on the programmes of which post-outcome data was available for 12. Of the parents of the 12 children who attended, 10 were mothers and the other two were couples (mother and father). The 10 mothers were co-habiting with partners at time of intervention. Six children met DSM-5 criteria for disruptive mood dysregulation disorder from clinical interview while the remaining seven met subthreshold criteria (difficulties not evident in at least two of three settings). Parents were predominantly from a high

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socioeconomic background with nine of the parents having at least a primary college degree. Ten of the children were male with the average age of children 7.8 (SD = 1.3).

No child was prescribed psychiatric medication at time of referral.

Intervention

All thirteen parents completed the manualised Triple P behavioural management group (Level 4; Sanders 1999).

Two groups were run in total by the main therapist who is an accredited Triple P facilitator. The Triple-P Level 4 group training programme is suitable for parents of children aged 2–12 years (group Triple-P). Five positive parenting principles provide the basis of the intervention and include:

having a safe, interesting environment, having a positive learning environment, using assertive discipline, having realistic expectations, and taking care of yourself as a parent.

The programme comprises of five (2-h) group sessions that educate parents and actively train parental skills to promote children’s development and manage children’s behaviour in a positive and constructive manner. In addition to the five group sessions, there are three (15–30 min) individual telephone consultations, following a self-regulatory format to facilitate independent problem solving. The telephone consultations provided parents with an opportunity to talk about and tailor the treatment strategies in managing temper outbursts and irritability. Of the five actual treatment sessions, parents seemed to respond particularly well to session 2, which focused on improving the parent–child relationship and increasing child independent skills. The average number of sessions attended was 4.4 out of a possible total of 5 sessions. Seven participants attended all five sessions (58.3%), three attended four (25%) and two attended three sessions (16.6%). Regarding the 3 telephone consultations, 8 (66%) of the parents took all 3 phone calls.

Outcome Measures

The primary outcomes were the Affective Reactivity Index for Parents (ARI-P; Stringaris et al. 2012) and the Retrospec- tive Modified Overt Aggression Scale (R-MOAS; Yudofsky et al. 1986). The ARI-P is a seven-item measure of irritability that has been shown to be a reliable and valid instrument (Stringaris et al. 2012). The R-MOAS is a 16-item tool that assesses four different areas: verbal aggression, physical aggression towards self, physical aggression towards others, and aggression towards property. The tool is psychometri- cally sound and has good internal consistency (Cronbach’s α = 0.82; Stringaris et al. 2018).

Secondary outcome measures included the Strengths and Difficulties Questionnaire (SDQ; Goodman 2001). For this pilot study, we included two of the five subscales, the

conduct and pro-social subscales. The SDQ has excellent psychometric properties with a mean Cronbach’s α = 0.73.

Finally, the Brief Assessment Checklists (BAC-C, Tarren- Sweeney 2013) was also used to gauge child behavioural difficulties. The instrument is reported to have adequate psychometric properties (Tarren-Sweeney 2013).

Results

Outcome measures for 12 families were included in the analysis. Paired samples t-tests were conducted on each of the outcome measures pre and post. No significant effect was found on the ARI-P. Results indicated a significant decrease on measures of overt aggression t (11) = 2.34, p = 0.03, as measured by the R-MOAS. On the behavioural measures, the conduct and pro-social subscales of the SDQ evidenced significant change at post-treatment. Specifically, there was a decrease in reported behavioural difficulties (conduct scale) and an increase in pro-social behaviours (pro-social scale) following treatment. Significant improvements were also evidenced on the BAC-C. See Table 1 for outcome measure scores.

Discussion

To our knowledge, this brief report is one of the first to focus solely on a well-established, empirically validated, parent management training program that specifically addressed symptoms of disruptive mood dysregulation disorder. Chronic irritability is a severe and debilitating condition that impacts on a range of different areas. The current study provides partial evidence regarding the sole use of a standardised parent management training program for children presenting with disruptive mood dysregulation

Table 1 Descriptive statistics and paired-samples t-test results at pre and post treatment (n = 12)

ARI-P Affective Reactivity Index-Parent, R-MOAS Retrospective Modified Overt Aggression Scale, SDQ-C Strengths and Difficulties Questionnaire-conduct subscale, SDQ-P Strengths and Difficulties Questionnaire-pro-social subscale, BAC-C Brief Assessment Check- list for Children

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Measure Mean (SD; N)

pre-therapy Mean (SD; N)

post-therapy t df Sig

ARI-P 6.7 (3) 5.1 (3.6) 1.60 11 .137

R-MOAS 12.5 (7) 8.4 (7.5) 2.34 11 .03*

SDQ-C 4.2 (1.5) 3.0 (1.5) 2.6 11 .024*

SDQ-P 5.7 (2.7) 6.8 (2.3) − 2.31 11 .041*

BAC-C 14.7 (6.2) 11.4 (5.5) 2.57 11 .026*

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disorder. Parents reported a non-significant reduction in irritability as measured by the ARI-P. In contrast, parent outcome measures evidenced significant reductions in child overt aggression, conduct problems, and an increase in pro-social behaviours.

Regarding the ARI-P, results indicated no significant improvement in irritability. It is possible that a child treatment component is necessary in addressing irritability. Research by Waxmonsky et al. (2016) reported significant reductions in irritability but these gains were not maintained at treatment follow-up. Further research may benefit from using multiple sources of assessment including teacher and clinician report measures of irritability.

While not surprising that behavioural difficulties were reduced, the study indicates that parent management training may be useful in addressing overt aggression and temper tantrums, which can be a specific consequence of disruptive mood dysregulation disorder. The broad spectrum of symptoms related to disruptive mood dysregulation disorder including externalizing and internal- izing difficulties suggest that a more intensive treatment approach involving the individual, parents, and school may be needed although parent management training may be a useful first-line treatment in helping address various types of aggression, specifically verbal aggression.

While promising, the current results are tentative and should not be considered empirically supported for this specific population. A minimum of 12 participants has been cited as necessary for a pilot study (Julious 2005) and other treatments focusing on disruptive mood dysregulation disorder and irritability have tended to have small sample sizes (Kircanski et al. 2018; Derella et al.

2020). However, the lack of a control group and the fact that the study was not randomised severely limits conclu- sions from this pilot study. Future research would benefit from including outcome measures that capture possible change in parental behaviours. Similarly, the sole focus on parent-report increases the likelihood of bias. The use of child and teacher reports in gaining a more nuanced perspective of child irritability symptoms would also be important in guiding further treatment considerations. It is hoped that this brief report highlights the potential use of standard parent management training in addressing various aspects of the difficulties underpinning disruptive mood dysregulation disorder. The findings from this pilot study and others (Derella et al. 2020) suggest that disruptive mood dysregulation disorder can be addressed effectively.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval The Health Service Executive (HSE) provided ethical approval for this study and authors’ research conduct was compliant with the ethical principles of the organisation.

Informed Consent All participants in this study provided informed consent for their involvement.

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