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A study of temperament in children with attention-deficit disorders asks, do we need an irritable subtype of ADHD? The authors found that about one-third of children recruited for a study of ADHD had significant irritability, which remained an identifying characteristic of that subgroup for over 3 years. Fifty percent of the irritable subgroup were taking a stimulant medication vs only 25% of the mild symptoms subgroup and 30% of a third group, which the authors called surgent. The surgent type was defined by high levels of activity, high intensity pleasure seeking, and assertiveness but not irritability. In other words, the irritable subtype, at least as subdivided in this study, remained stable over time and was more likely to be treated with a stimulant. So, one could ask, how well do current ADHD treatments work in this subgroup?
Hi! Jim Phelps here for the Psychopharmacology Institute. The idea for this Quick Take was to look at a mini-review of pharmacologic and psychosocial interventions for reducing irritability in kids with ADHD. What works? It turns out that studies with data on this question have very different designs and examined quite different populations, such as ADHD combined with disruptive mood dysregulation disorder (DMDD), severe mood disorders, or autism spectrum disorders. So, this mini-review is not really looking at irritable ADHD per se.
The bottom line based on 12 studies: Overall, everything works for irritability in ADHD—stimulants, parent training, and, perhaps to a lesser extent, atomoxetine and guanfacine. However, the review cites an important 2021 study of stepped treatment for ADHD and aggression by Joseph Blader and colleagues. That study found that aggression remitted in 63% of the participants with rigorous titration of stimulant medication and concurrent parent training. Interestingly, the plan was to randomize kids to risperidone, divalproex, or placebo but only after stimulant optimization and family training was complete. And lo, more than half of the enrollees never made it to randomization, and all of these kids already had previous stimulant treatment.
Here’s a key consideration for this result. The behavioral training was done family by family, not in groups, at their child’s clinic visit for stimulant optimization, so attendance was excellent. Sessions included goal setting, increasing positive interactions with the child and rewarding cooperative behavior and composure, judicious ignoring of low-level misbehaviors, a system to reward cooperation and improve frustration tolerance, and plans for handling uncooperative and dyscontrolled behavior.
How did they do the stimulant optimization? That protocol began with all the kids on extended-release methylphenidate. Another potential key ingredient in this stimulant optimization was weekly titration based on data from 4 different scales: The Conners Global Index Parent Version, with the Teachers Version being sometimes available as well; Overt Aggression Scale; and Adverse Effect Scale. The dose was increased by 18 mg steps until response, problems, or a dose of 90 mg daily. Insufficient or adverse responses led to switching to extended-release mixed amphetamine salts. That was it. That’s the program, combined parent training and rigorous optimization of stimulant doses, that led to a 63% remission rate in kids who had already had stimulant treatment.
So, you can understand how the authors of the new mini-review arrived at their main conclusion. “Multiple attempts to optimize stimulant dose and engage families in evidence-based parenting interventions appear prudent before consideration of adjunctive medications with potentially more problematic tolerability profiles such as antipsychotics.” The authors also note that adding behavioral therapy after medication results in poorer attendance for therapy sessions, and that results in reduced efficacy for that sequence.
For more on all this, the United States Centers for Disease Control and Prevention has a webpage on parent training in behavioral management of ADHD, which is linked here at the Psychopharmacology Institute. It has handouts for parents that might help you direct families to therapists in your area. If you know of such therapists and can make direct referrals, that would be ideal.
Abstract
Approximately a third of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) experience significant irritability; despite this, no study has reviewed whether interventions for youth with ADHD can improve irritability. This mini review sought to address this gap in the literature by discussing existing pharmacological and psychosocial interventions for irritability among children and adolescents with ADHD. A literature search was conducted in April 2021, with a total of 12 intervention articles identified (six pharmacological, one psychosocial, five combined). Studies were excluded if they did not involve an intervention, a measure of irritability, or the population was not youth with ADHD. Of these articles, two were with an ADHD only sample; seven included ADHD with comorbid disruptive behavior, disruptive mood dysregulation disorder (DMDD), or severe mood dysregulation (SMD); and three included ADHD with comorbid autism spectrum disorder (ASD). Findings suggest that central nervous system stimulants used alone or in combination with behavior therapy are effective at reducing irritability in youth with ADHD only or comorbid ADHD and DMDD/SMD. Less evidence was found for the efficacy of guanfacine and atomoxetine for youth with ADHD only or comorbid ADHD and ASD. Parent training alone or in combination with atomoxetine was found to be effective at reducing irritability in youth with comorbid ADHD and ASD. Future research assessing the efficacy of other psychosocial interventions, particularly cognitive behavioral therapy is necessary, as are randomized trials assessing intervention sequencing and intensity among youth with ADHD. Researchers are advised to utilize well-validated measures of irritability in future research.
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Reference
Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, R. (2022). A mini-review of pharmacological and psychosocial interventions for reducing irritability among youth with ADHD. Frontiers in Psychiatry, 13.
Related References
- Blader, J. C., Pliszka, S. R., Kafantaris, V., Foley, C. A., Carlson, G. A., Crowell, J. A., … & Margulies, D. M. (2021). 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. Journal of the American Academy of Child & Adolescent Psychiatry, 60(2), 236-251.
- Centers for Disease Control and Prevention. (2020, September 4). Behavior therapy for young children with ADHD | CDC. https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html
