Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability

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Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability Rebecca A. Grossman and Jill Ehrenreich-May, University of MiamiUniversity of Miami The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C and UP-A) are evidence-based treatment programs with cognitive-behavioral and third-wave behavior therapy elements, aimed at extinguishing distress to intense emotion states and reducing unhelpful action tendencies in such states among youth with emotional disorders. A growing body of literature demonstrates the high prevalence of problematic anger and irritability among youth with emotional disorders, yet evidence-based treatments to address anger and irritability are typically developed more exclusively for youth with externalizing disorders. Given this need, a clinical case example of the UP-C applied to a child with anger and irritability is presented. Application of transdiagnostic theory to both conventional anxiety concerns and to irritability concerns is discussed. We demonstrate the flexibility and utility of a transdiagnostic approach like the UP-A and UP-C for addressing concerns across a range of emotions.

has been described as the “forgotten emotion” in mental health research and treatment (DiGiuseppe & Tafrate, 2006). This dearth of literature is particularly apparent in research on youth emotional disorders, which include depressive disorders, anxiety disorders, obsessive-compulsive disorders, and traumaand stressor-related disorders. Research focuses less on anger in the context of emotional disorders because these are typically characterized as disorders of “flight,” rather than “fight” (Kunimatsu & Marsee, 2012). Indeed, many dimensional models of psychopathology have distinguished internalizing disorders (including emotional disorders), which are typically characterized by withdrawal behavior, from externalizing disorders, in which negative emotionality is outwardly expressed (e.g., Kotov et al., 2017; Krueger, McGue, & Iacono, 2001). Yet epidemiological research demonstrates that externalizing and internalizing disorders commonly co-occur (Angold & Costello, 1999). Furthermore, there is a small but growing body of evidence indicating that anger-related (i.e., “fight”) symptoms are indeed elevated among youth with primary emotional disorders, even without diagnosable externalizing disorders. For example, research on both depression and anxiety in children indicates that many of these youth present for treatment with concerns about frequent anger outbursts and tantrums (Cassiello-Robbins & Barlow, 2016;

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Keywords: Unified Protocol; transdiagnostic; anger; irritability; child

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Fava & Rosenbaum, 1998; Painuly, Grover, Gupta, & Mattoo, 2011; Poznanski & Zrull, 1970). Importantly, some evidence suggests that anger may be qualitatively different in the context of internalizing problems. For example, several studies have demonstrated the specificity of cognitive distortions related to internalizing problems and comorbid externalizing problems (Epkins, 2000; Leung & Wong, 1998). In a sample of adolescents, cognitive distortions such as selective abstraction, catastrophizing, and overgeneralization were stronger predictors of internalizing problems alone and co-occurring internalizing/externalizing problems than of externalizing problems alone (Epkins, 2000; Leung & Wong, 1998). In addition, adolescents with internalizing problems and those with both internalizing and externalizing problems are more likely to use cognitive emotion regulation strategies such as self-blame and rumination when compared with externalizing-only teens (Garnefski, Kraaij, & van Etten, 2005). At the symptom level, others have posited that anxiety and externalizing behavior may co-occur because efforts to avoid anxiety-provoking stimuli may be interpreted as oppositional behavior, suggesting that anger in the presence of emotional disorders is the result of distinct triggers (Bubier & Drabick, 2009). Taken together, these findings suggest the need for a treatment that flexibly incorporates the unique aspects of anger that may occur in the context of emotional disorders based on a comprehensive model that reflects the etiology and maintenance of these problems. Although there are several established treatments for anger in the context of externalizing disorders (for a review, see Sukhodolsky, Kassinove, & Gorman, 2004), none of these current treatments for youth address the

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

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presentation of anger in emotional disorders, specifically. Given the well-documented consequences of unmanaged anger for both physical and mental health (DiGiuseppe, Tafrate, & Eckhardt, 1994), there is a clear need for appropriate evidence-based interventions to address such concerns. The purpose of this article is to present the application of a transdiagnostic treatment for youth emotional disorders (J. T.Ehrenreich-May et al., 2018) in the context of children presenting with frequent or severe anger outbursts and/or irritability (with or without diagnosable externalizing problems). First, we examine the literature on the prevalence of anger in youth with primary depressive, anxiety, or other emotional disorders, as well as current treatments available to target anger in children and adolescents. Next, we discuss the rationale for using a transdiagnostic treatment approach for anger and irritability in youth, like the UP-C and UP-A, followed by a case example demonstrating how this treatment can be adapted to target anger in the context of emotional disorders.

The Role of Anger in Youth Emotional Disorders To understand anger as it presents in youth with emotional disorders, several definitional issues must first be addressed, as the term is often conflated with other emotions and behaviors (DiGiuseppe & Tafrate, 2006). In this case discussion, we base our definition of anger on that of DiGiuseppe and Tafrate (2006): “Anger is a subjectively experienced emotional state with high sympathetic autonomic arousal . . . initially elicited by a perception of threat . . .” (p. 21). Though the term “irritability” is often used interchangeably with the term “anger,” the DSM-5 defines irritability as “persistent anger, a tendency to respond to events with angry outbursts or blaming others, an exaggerated sense of frustration over minor matters” (American Psychiatric Association, 2013, p. 163). Irritability refers primarily to the quality of having a low threshold to experience or express anger. Given the overlap in these definitions and the varied presentation of youth emotional disorders, our review of the role of anger discusses literature that addresses all of these concepts. Thus, we include studies examining not only anger, but also irritability, aggressive behavior, and related concepts. While there is substantial evidence for the co-occurrence of externalizing disorders and internalizing disorders, this review focuses on studies that examined children with primary internalizing problems, and those that measured anger and irritability dimensionally rather than categorically (i.e., the presence or absence of a comorbid externalizing disorder). Though the body of research is somewhat limited, findings consistently point to the large role that anger

plays in the presentation and experience of emotional disorders, both in terms of comorbid externalizing disorders and in co-occurring symptoms that may not reach the level of a clinical diagnosis. In a clinically referred sample of nearly 200 children and adolescents diagnosed with major depressive disorder (MDD), “irritability and anger” were the fourth most common symptom cluster reported, with 83% of the sample endorsing this symptom (Ryan et al., 1987). This is consistent with early case reports of depressed youth, most of whom were referred due to aggressive outbursts, only to later be diagnosed with a depressive disorder after further clinical evaluation, rather than an externalizing disorder (Poznanski & Zrull, 1970). More recent work indicates that children with anxiety disorders are significantly more irritable than healthy control children, and such irritability is not uniquely associated with a diagnosis of generalized anxiety disorder, which lists irritability among its symptoms in the DSM-5 (Cornacchio, Crum, Coxe, Pincus, & Comer, 2016; Stoddard et al., 2014). Research on anger and irritability in obsessivecompulsive disorders (OCD) is also limited, but findings suggest that elevated anger is indeed associated with childhood OCD. In a sample of youth with OCD, nearly 55% exhibited anger in the clinically significant range over the week prior to the clinician assessment (Storch et al., 2012). In addition, McGuire et al. (2013) found that 20% of a sample of children diagnosed with OCD met the clinically significant threshold on the Child Behavior Checklist–Dysregulation Profile, which includes the Anxious/Depressed, Aggressive Behavior, and Attention Problems syndrome scales of the measure. The occurrence of anger in adult trauma clients is also well documented (e.g., Olatunji, Ciesielski, & Tolin, 2010; Rodenburg, Heesink, & Drožđek, 2014), though there is less research on anger in children with trauma- and stressor-related disorders. However, research findings indicate that anger and rage are associated with post (PTSD) in children and adolescents. For example, higher levels of both active and passive aggression were linked uniquely to a diagnosis of PTSD compared to those without PTSD in a sample of juvenile offenders (Schrack, 1996). Similarly, Saigh, Yasik, Oberfield, and Halamandaris (2007) found that youth with PTSD had significantly higher scores on the State-Trait Anger Expression Inventory State and Trait Anger subscales (Spielberger, 1996), as well as the Angry Temperament Subscales, than trauma-exposed youth without PTSD. Contrary to the assumption that emotional disorders are associated only with withdrawal and inhibition (Kunimatsu & Marsee, 2012), the evidence reviewed indicates that anger and irritability are highly prevalent and problematic in this population.

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger Existing Treatments for Anger To date, cognitive-behavioral treatments (CBTs) are the most widely researched interventions for youth anger (Blake & Hamrin, 2007). A variety of cognitive-behavioral interventions targeting anger have been developed, primarily focusing on anger in the context of externalizing disorders. The majority of these treatments involve a range of skills that target both internal states and external expression of anger (cognitive and behavioral skills, respectively), and most are delivered in a group format (Sukhodolsky et al., 2004). Because child-directed CBT is often considered a primary approach for treating anger and aggression in youth, and is the most well-studied of these treatments (Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016), a brief description of its treatment components provides additional context for the application of the approaches described in the UP-C and UP-A. CBT for anger includes three primary modules, the first of which targets emotion regulation. This module includes psychoeducation about the cognitive-behavioral model of anger/aggression, teaches children to identify internal and external triggers of anger/aggression, establishes strategies to prevent unhelpful behavioral responses (i.e., aggression), introduces cognitive reappraisal, and teaches relaxation skills. The second module addresses social problem-solving, including demonstrating how to identify a variety of solutions for angerprovoking situations and teaching children how to consider the consequences of their behavioral responses. The final section addresses skills to prevent and resolve anger-provoking situations with others, including how to communicate effectively with adults when angry, and practice role-playing appropriate behavioral reactions. The manual also includes several parent-focused sessions to establish the role of parents as “coaches” for the child, and to address behavioral concerns through effective parent management, such as selective attention, delivering effective commands, and reinforcing the use of new skills. Such strategies are consistent with other cognitive behavioral interventions for anger and aggression in children. A meta-analysis by Sukhodolsky et al. (2004) suggests that treatments for youth anger focused on social skills development and those that involved teaching multiple strategies were superior to treatments focused on affective education alone. In addition, treatments that involve teaching new, more helpful behaviors are more effective than those targeting internal experiences related to anger (i.e., cognitive strategies). Modeling of skills and providing feedback, as well as the between-session practice of skills were also associated with larger effect sizes (Sukhodolsky et al., 2004). Extending these findings for

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the treatment of anger in youth emotional disorders, the UP-C and UP-A may be good choices for targeting problematic anger-related behaviors. Like existing evidence-based interventions for anger, the UP-C and UP-A are CBT programs with a strong emphasis on behavior modification, supported by cognitive skills, though they are unique in their emotion-focused content. The UP-C is also delivered in group-based format but can be used with individual clients.

Limitations of Existing Treatments for Youth Emotional Disorders While there is substantial empirical support for the effectiveness of single-disorder (e.g., social anxiety disorder, major depressive disorder, etc.) or singledomain (e.g., anxiety, depression, etc.) interventions to treat youth emotional disorders, there is relatively little research on targeted efforts to manage symptoms of anger and irritability in children with emotional disorders (e.g., Caporino, Herres, Kendall, & Wolk, 2015; Johnco et al., 2015; Storch et al., 2012; Stringaris, Maughan, Copeland, Costello, & Angold, 2013). To date, findings are inconsistent regarding the effects of traditional CBT to treat anger and irritability in youth emotional disorders. In one study, CBT for youth anxiety disorders was shown to be effective for reducing anger episodes at posttreatment (Johnco et al., 2015). On the other hand, Suveg, Sood, Comer, and Kendall (2009) found that measures of emotion regulation of anger did not improve in a sample of anxious youth after a course of CBT for anxiety. Other transdiagnostic treatment approaches (e.g., MATCH and FIRST; Chorpita & Weisz, 2009; Weisz et al., 2012) that involve skills to address both internalizing and externalizing symptoms are a potential alternative for addressing anger/irritability in the context of emotional disorders. These treatments, which rely on a “common elements” approach by identifying shared treatment strategies from across disorder-specific approaches, may be particularly useful for clinics where efficiency of the treatment approach is a main factor in treatment choice (Chorpita, Daleiden, & Weisz, 2005). The advantage of the UP-A/C, however, is the underlying unifying theory which provides a comprehensive explanation for emotional concerns (described below) that can be utilized by the clinician to make treatment decisions flexibly from available UP materials. Given these limited findings and mixed results, as well as the large proportion of youth with emotional disorders who also present for treatment with frequent and intense anger episodes, it follows that adaptations to existing treatments, particularly those that are transdiagnostic and

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

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emotion-focused, may be an important step in addressing these commonly co-occurring concerns. Rationale for the Use of the UP With Youth Anger and Irritability Theoretical models regarding the overlap and comorbidity of emotional disorders (e.g., Insel et al., 2010; Kotov et al., 2017) may be useful in understanding the role of anger in the context of such disorders in youth. For example, Barlow, Sauer-Zavala, Carl, Bullis, and Ellard (2014) posited that depression, anxiety, and related disorders may be understood as manifestations of higher-order neuroticism or negative affect—that is, the propensity to react to stress by frequently experiencing strong negative emotions and intense reactions to such emotions. This model, which underlies the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2018) and the downward adaptations for children and adolescents (UP-C and UPA, respectively), is particularly well-suited to explain the role of anger in emotional disorders, as anger is among the most frequently experienced negative emotions, and is thought to maintain problematic emotion regulation strategies (e.g., aggression, anger outbursts; Cassiello-Robbins & Barlow, 2016). Different from other treatments for youth emotional disorders, which tend to have a narrower focus on a single emotion, the UP focuses on emotions more broadly. Within the UP, rather than targeting the emotions themselves, treatment focuses on modifying the way individuals respond to various emotions and the way they experience these emotional states (Trosper, Buzzella, Bennett, & Ehrenreich, 2009). For example, using nonjudgmental awareness strategies, the UP encourages children to experience their thoughts more mindfully and neutrally, rather than engaging in rumination or suppression (J. T. Ehrenreich-May et al., 2018). Techniques like this one that are presented in the UP-A and UP-C can be applied to a range of emotions, such as sadness and anxiety. The UP-A and UP-C have been examined in open trials, waitlist controlled trials, and randomized trials with an active comparison condition (Bilek & Ehrenreich-May, 2012; Ehrenreich-May et al., 2017; Kennedy, Bilek, & Ehrenreich-May, 2018). The UP-C, specifically, has demonstrated equivalence to an anxiety-focused group CBT protocol for children, with similar rates of remission in principal diagnoses (61.9% versus 57.9% for the UP-C and anxiety-focused group, respectively; Kennedy, Bilek, & Ehrenreich-May, 2018). Furthermore, several advantages of the UP-C were observed in this study, including faster declines in sadness dysregulation compared to the control group, and greater improvements in cognitive reappraisal, with maintenance at 6-month follow-up

(Kennedy, Bilek, & Ehrenreich-May, 2018). While some studies have demonstrated that comorbid depression predicts poorer response to manualized CBT for anxiety disorders (Ginsburg et al., 2011; Jakubovski & Bloch, 2016; Lundkvist-Houndoumadi & Thastum, 2017), results for the UP-C demonstrated that comorbid depression was a positive predictor of remission, which suggests the potential superiority of this transdiagnostic approach. A further review of the evidence base for the UP-A and UP-C can be found in J. T. Ehrenreich-May et al. (2018). Application of the UP for Transdiagnostic Treatment of Emotional Disorders for Children to Anger and Irritability In order to demonstrate the application of the UP to youth with anger difficulties, this report will describe the case of Zara, an 8-year-old White, Hispanic female presenting for treatment at University-based specialty research clinic due to frequent irritability and difficulty sleeping alone and separating from her mother. The name and several demographic details of Zara’s case have been changed to protect the privacy of her family. Zara was treated using the UP-C, a group version of the UP tailored to the developmental needs of 6- to 12-year-old youth (J. T.Ehrenreich-May et al., 2018). Following a description of Zara’s case, a full description of the UP-C and its application to Zara’s anger-related concerns is provided. We wish to note that in this case example we focus on the ways in which the UP-C was applied to Zara’s anger-related concerns, but that other, more traditional treatment targets (e.g., anxiety, sadness) were also addressed during the course of therapy. The tailoring approaches described in this article were based on Zara’s presenting concerns and family composition. It should be noted that the UP-C and UP-A were initially developed and tested on samples that were predominantly Hispanic/Latino(a) (Bilek & Ehrenreich-May, 2012; Ehrenreich-May et al., 2017; Ehrenreich, Goldstein, Wright, & Barlow, 2009; Kennedy, Bilek, & Ehrenreich-May, 2018; Kennedy, Tonarely, Sherman, & Ehrenreich-May, 2018), and have produced positive outcomes for these diverse samples, regardless of demographic characteristics. For a further review of cultural adaptations of evidence-based treatments, readers are directed to Pina, Villalta, and Zerr (2009) and Lau (2006). Background and Presenting Problems Zara presented for treatment the summer before entering the third grade, after which her mother, stepfather, and she would be moving out of state. Both she and her mother spoke English and treatment was conducted in English. She was reportedly a typically

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger developing child, with no notable concerns in her medical or developmental history. Zara’s mother, referred to here as Mrs. B, and her father divorced when Zara was 2 years old. According to her mother’s report, Zara’s biological father had a history of mental illness and was said to be relatively unstable as a caregiver, reaching out to see her only a few times a year. Three years prior to presenting for treatment, Mrs. B began a new romantic relationship. Mrs. B then remarried 3 months before she brought Zara to the clinic, which appeared to coincide with the onset of Zara’s difficulties. Zara lived with her mother and stepfather, and she had several adult halfsiblings with whom she was close. She also frequently spent time with her extended family. Prior to intake, Zara had been seeing a licensed clinical social worker weekly for 3 years on and off, who provided supportive psychotherapy related to her parents’ divorce. She was referred to the program by this therapist due to an increase in her separation anxiety concerns, for which it was felt Zara would benefit from exposure-based CBT. At the time of the evaluation, Zara had terminated with her previous therapist in order to begin services at the clinic. Zara was assessed using the Anxiety Disorders Interview Schedule for DSM-5 Child/Parent Report (ADIS-5 C/P; Silverman and Albano, in press). At the time of intake, Zara presented with concerns about separating from her mother that had escalated approximately 5 weeks prior, coinciding with her mother’s remarriage. With the exception of school, Zara was having difficulty staying with extended family when her mother was away and was having difficulty being in a different room than her mother. When separating from her mother, she would frequently complain of stomachaches and headaches. Zara reported that she worried about her mother’s safety when they were apart and would call frequently when her mother was not at home with her. Zara was also having difficulty sleeping through the night, and would often wake up and yell for her mother. If Mrs. B did not immediately come to lay down with her, Zara’s behavior would escalate and become aggressive, and she would begin kicking things around the house and shouting. Zara was experiencing difficulty separating from her mother for approximately 5 weeks at the time of intake. In addition, Mrs. B reported that Zara would become upset for reasons that were unclear, and begin grunting and whining, without verbally expressing what she was feeling. She would reportedly kick things, yell, scratch, and hit herself, which was very distressing for her mother and disruptive to the family routine. Mrs. B reported that she was often touchy and easily annoyed, and frequently argued with her mother and other authority figures in the house. Mrs. B reported that these symptoms became problematic approximately 3 years before the assessment.

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Further, Zara was described as perfectionistic, at times becoming angry if she did not like how her hair looked or if she lost in a game. She reported that she worried about their house being robbed and that she often had difficulty falling asleep because she was worrying about a range of things. These symptoms were longstanding and Mrs. B described Zara as a worrier from a very young age. On the basis of the ADIS-5 C/P report, Zara was diagnosed with primary separation anxiety disorder (SAD), as well as oppositional-defiant disorder (ODD) and generalized anxiety disorder (GAD). Assessment In addition to the ADIS-5 C/P, Zara and her mother completed measures to assess her progress throughout treatment. Session-by-session assessment included rating of Top Problems, based on Weisz et al. (2011). The Top Problems identified by Zara and her mother included, “sleeping alone at night,” “handling my anger,” and “feeling sad when people talk about my dad.” At the start of treatment, these were rated as on an 8-point scale as 8, 8, and 5, respectively, by Zara’s mother, and 8, 8, and 6 by Zara. Ratings were taken at each session. The Children’s Emotion Management Scale–Anger (CEMS-Child and CEMS-Parent; Zeman, Shipman, & Penza-Clyve, 2001) was also collected from Zara and Mrs. B at each session. This child-report measure assesses strategies used to regulate emotions. Specifically, the measure includes an Inhibition subscale, which addresses suppressing or hiding emotions, a Dysregulation subscale, which addresses inappropriate expression of emotions, and a Coping subscale, which addresses constructive use of strategies to control emotional behaviors. Higher scores on the Inhibition and Dysregulation subscales represent poorer anger management, while higher scores on the Coping subscale represent more adaptive management of anger. The measure has been used in previous studies as a child-self report tool. In Zara’s case, it was also administered to the parent, with item wording modified accordingly (e.g., “when I am angry” to “when my child is angry”). Psychometric properties of the measure are acceptable and can be found in Zeman et al. (2001) and Suveg et al. (2009). The CEMS scores reported at the beginning of the first session were derived by summing the total of the items on each subscale and dividing by the number of items on that scale, such that a score of 3 was the maximum possible score on each scale. Scores are presented in Table 1. Mrs. B reported relatively high scores for both the Anger Dysregulation and Anger Inhibition subscales. This suggests that she perceived Zara as expressing anger in observably inappropriate ways (Dysregulation) and also perceived her as frequently suppressing or masking her anger maladaptively

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Grossman & Ehrenreich-May

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Table 1

Pretreatment CEMS Scores CEMS Subscale

Parent

Child

Anger Inhibition Anger Dysregulation Anger Coping

2.25 3 1

1 2.33 1

Note: CEMS = Children’s Emotion Management Scale

(Inhibition). Zara self-reported similarly elevated levels of Anger Dysregulation, but did not report high scores on Anger Inhibition. This discrepancy may have been due to her level of insight at the start of treatment regarding her emotional experiences. Case Conceptualization Conceptualization of Zara’s case was based on the theory of neuroticism as a core construct underlying emotional disorders, which is consistent with the UP treatment (Barlow et al., 2014). According to this theory, individuals high in neuroticism, and negative affect, by extension, are thought to experience fear, anger, sadness, and anxiety more frequently and more intensely than others do. Further, these individuals are likely to experience high levels of distress and discomfort as a result of these strong emotions and may turn to avoidance, suppression, or other unhelpful strategies to reduce uncomfortable emotions (Barlow & Kennedy, 2016; Barlow et al., 2014). Zara appeared to have low tolerance for discomfort and distress, and frequently responded with intense emotional behavior when she was anxious or upset. This aversion for distress was also evident in her intolerance of negative emotions, as she often had difficulty even discussing negative emotional experiences. Consistent with the UP model, both Zara’s intense angry outbursts and her avoidance behavior were negatively reinforced by short-term relief from uncomfortable emotions but prevented her from developing more helpful and appropriate strategies for coping with such emotions. These intense reactions may also have been partially maintained by her mother’s response. For example, Zara found that she was able to elicit attention from her mother in the form of concern and worry when she became angry and aggressive towards herself. The response from her mother served to reinforce this behavior and maintain these tendencies. Zara learned that she could eventually get her mother’s attention if she continued to push the boundaries, and her mother’s intervention also impaired Zara’s development of effective coping strategies. In addition, Zara’s learning experiences and intolerance of uncomfortable emotions resulted in a fear of

being separated from her mother, as Zara’s mother often facilitated her avoidance of these situations by ensuring that she was nearby. As such, Zara was unable to learn how to cope with separation and received negative reinforcement from her mother in many of these situations. In line with the underlying theory of the UP, treatment was designed to focus on modifying maladaptive emotion regulation strategies by teaching Zara antecedent cognitive reappraisal, prevention of emotional avoidance (with the involvement of her mother, by teaching behavioral strategies), and modifying Zara’s emotional action tendencies through “acting opposite” and behavioral contingencies.

Treatment The UP-C was presented to Zara in a group format across 15 sessions. During sessions 1 through 10, parents and children spent part of the time meeting separately, providing the opportunity for parents to learn skills presented to the children, as well as additional parentfocused strategies to support treatment (e.g., using consistent praise and reinforcement, reducing accommodation). The final sessions involved graduated, situational emotion exposure, followed by a session of review and relapse prevention. Techniques in the UP-C are divided into five CLUES Skills presented sequentially over several sessions that follow a detective theme to encourage children to “solve the mystery of their emotions.” Skills include, “Consider how I feel,” “Look at my thoughts,” “Use detective thinking,” “Experience my emotions,” and “Stay happy and healthy.” Each of the CLUES Skills covers core strategies of the UP model that children learn. In addition to teaching parents about the skills for children, parents learn about four common strategies that are often unhelpful for managing children’s emotions (Emotional Parenting Behaviors) as well as four Opposite Parenting Behaviors that can be used as more effective approaches to support emotion regulation. Session content is detailed further below along with descriptions of how these skills may be applied to anger and irritability using examples from Zara’s case. A summary of the session goals can be found in Table 2. Zara participated in the group with four other children of similar ages, all of whom presented with primary diagnoses of an emotional disorder. Five advanced doctoral student therapists who were trained in the UPC facilitated the group. Each session, two therapists were designated to work with the parent group, and three therapists worked with the group of five children. Each family was assigned to one of the lead therapists, who served as a “point person.” This therapist was responsible for communicating with the family between sessions as needed, checking in with the family at the start of sessions, collecting assessment materials, and working with the

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger family to facilitate the application of skills for the child’s needs. Because of this level of personalization, anecdotally, we have found the ideal ratio of therapists to children is 1:2. In Zara’s case, what is described below represents strategies that were presented to all of the children in the group, as well as the ways in which these strategies were applied for Zara’s specific concerns. Given this structure, the UP-C can be used for individual clients with relatively few modifications (see J. T.Ehrenreich-May et al., 2018, for a description of individual therapy applications). Consider How I Feel (C Skill) The first skill, the C Skill, included psychoeducation and an introduction to the concept of “emotional behaviors” and opposite action. The content began with a focus on the purpose of emotions and their associated emotional behaviors. Consistent with the UP model, emotions were presented as natural and harmless, and children were introduced to the notion that each emotion serves a purpose and is associated with an emotional behavior, which may be adaptive or maladaptive. The discussion involved both positive and negative emotions. Children were encouraged to identify emotions they might feel in various situations, and their subsequent emotional behaviors. In Zara’s case, this involved a discussion about her anger in the context of becoming upset when she was corrected or when she lost a game. Here, the purpose of her anger was to defend her feelings that she was correct or to defend her integrity. As a result, her emotional behavior was to argue or shout. The psychoeducation about emotions then extended to the introduction of a cognitive-behavioral model, where Zara learned to break down emotions into the “Before, During and After.” Specifically, children practiced identifying the trigger for their emotion (Before), breaking the emotion down into thoughts, body feelings, and behaviors (During), and identifying the consequences of their emotional behavior (After). The group was presented with the “Cycle of Emotional Behavior”: the idea that maladaptive emotional behaviors such as avoidance or yelling may lead to further consequences (e.g., maintaining the fear or getting in trouble in the case of avoidance, and yelling in the case of anger), despite short-term immediate relief. For example, despite the potential for feeling some relief by kicking and yelling at her mother when she did not get her way, this often left Zara feeling guilty for having treated her mother poorly and feeling embarrassed about her behavior. Using Socratic questioning to help her apply this to her own experiences, Zara was able to recognize how her behavior might lead to further unpleasant emotions. The introduction of the Cycle of Emotional Behavior was particularly relevant for Mrs. B. Similar to other

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anxious children displaying angry behavior, Zara’s behavior was often triggered by anxiety-provoking situations, such as waking up in the middle of the night. This psychoeducation helped Mrs. B better understand the range of triggers for Zara’s anger. Through this dialogue, Mrs. B was also able to see how she might be inadvertently reinforcing Zara’s angry behavior (triggered by anxiety or otherwise) by acceding to her demands in order to calm her down. This was done through introduction and tracking in the Double Before, During, and After exercise, a functional assessment tool in which Mrs. B identified her own thoughts, feelings, and behaviors in response to Zara, as well as the consequences of these behaviors for both herself and for Zara. For example, Mrs. B might be triggered by Zara waking her up at night, which would result in feelings of tension, and the thought that she would not be able to get enough rest unless she went to sleep in Zara’s room. Mrs. B’s behavior of sleeping in Zara’s room would calm Zara down in the short-term, but reinforce her calling for her mother at night rather than encouraging her to put herself back to sleep. To further demonstrate the link between emotions and emotional behaviors, the group played the True Alarm/False Alarm game. Zara and the other group participants read various descriptions of emotional experiences and emotional behaviors, and they had to identify whether the scenario involved a high likelihood of danger and therefore warranted the associated emotional behavior, or whether the danger was simply perceived as dangerous and did not require the emotional behavior. When discussing anger-related behavior with Zara, this language was helpful throughout treatment, as Zara was prompted to consider whether her emotional behavior had been triggered by a true or false alarm and whether the situation involved a threat that warranted aggressive behavior in order to defend herself. Extending the discussion of the Double Before, During, and After, and the role of parent behaviors in their child’s emotional experience, parents in the group were introduced to four key “emotional parenting behaviors” and their opposite parenting behaviors. Specifically, these included overcontrol/overprotection (opposite behavior: healthy independence-granting), criticism (opposite behavior: positive reinforcement, differential attention, and empathy), inconsistency (opposite behavior: consistent discipline and praise), excessive modeling of strong emotions and avoidance (opposite behavior: healthy emotional modeling). For Mrs. B, inconsistency and criticism were particularly relevant. Contingencies for Zara’s emotional outbursts varied, and consistent consequences for such behavior (as well as rewards for staying calm) were absent when she entered treatment. In addition, Mrs. B often expressed a

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Grossman & Ehrenreich-May

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Table 2

UP-C Session-by-Session Content CLUES Skill

Session

Child Group

Parent Group

Consider How I Feel

1

• Introduce treatment model and structure • Identify treatment goals • Rapport-building among group • Psychoeducation • Psychoeducation and normalization of emotional experiences • Introduce three-component model of emotional experiences • Introduce cycle of emotional behaviors • Identify rewards for new behaviors • Introduce Acting Opposite • Learn the connection between activity level and mood (Behavioral Activation) • Introduce behavioral experiments to track activity and mood level • Introduce body clues and their relation to strong emotions • Practice identifying body clues for different emotions • Teach Body Scanning • Practice experiencing body clues without avoidance • Introduce cognitive flexibility • Teach how to recognize Thinking Traps

• Introduce treatment model and structure • Introduce three-component model of emotional experiences • Introduce cycle of emotional behaviors

2

3

4

Use Detective Thinking and Problem Solving

Experience My Emotions

5

6

• Introduce and apply Detective Thinking

7

• Introduce and apply Problem Solving

8

• Introduce and practice Present-moment and Non-judgmental awareness

9

• Review skills learned to date • Review concept of emotional behaviors and “acting opposite” to prepare for exposure • Demonstration of exposure • Work with parents to finalize Emotional Behavior Form

10

• Review exposure rationale • Introduce the concept of safety behaviors and subtle avoidance behaviors

• Introduce parents to the Double Before, During, and After (BDA) • Introduce Emotional Parenting Behaviors and Opposite Parenting Behaviors • Discuss use of positive reinforcement over criticism • Introduce Opposite Action • Discuss how parents can support Opposite Action • Discuss ways to reinforce children • Introduce somatization • Teach parents Body Scanning • Introduce sensational exposures and practice them • Teach parents about expressing empathy

• Introduce cognitive flexibility and common thinking traps • Discuss emotional parenting behavior of inconsistency, introduce opposite behavior of consistent reinforcement and discipline • Introduce and apply Detective Thinking • Introduce emotional parenting behavior of overcontrol/overprotection and independence-granting • Introduce and apply Problem Solving • Discuss use of Problem Solving for interpersonal conflict • Discuss reassurance-seeking and accommodation • Discuss importance of experiencing emotions rather than avoiding • Introduce and practice Present-moment and Non-judgmental awareness • Begin completing Emotional Behavior Form • Introduce the concept of situational exposure • Explain parents’ role in practice exposures at home • Introduce emotional parenting behavior of excessive modeling of intense emotions and avoidance, as well as opposite parenting behavior of healthy emotional modeling • Continue to develop Emotional Behavior Form to prepare for exposures • Review exposure rationale and application to a variety of symptoms • Introduce and discuss safety behaviors

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger

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Table 2 (continued) CLUES Skill

Stay Happy and Healthy

Session

Child Group

Parent Group

• Practice a group exposure • Plan for individual exposures

• Discuss use of opposite parenting behaviors to support exposures • Finalize Emotional Behavior Form, introduce and develop step-by-step exposure plans (Emotion Ladder)

11-14

• Conduct situational exposures

• N/A

15

• Review skills learned • Plan for facing strong emotions in the future • Celebrate progress!

• Review skills learned, including parent skills • Discuss and celebrate progress • Plan for sustaining progress after treatment • Discuss the difference between lapses and relapses and help parents recognize signs of relapse

great deal of distress and disappointment with Zara’s emotional outbursts, which may have further motivated Zara to avoid discussing these situations. After the children learned about the effect of emotions on behavior, the next session focused on the effect of behavior on emotions. The group conducted “experiments” in and out of session to demonstrate the effect of “acting opposite” in the face of uncomfortable emotions. In the case of depressive symptoms, this included identifying pleasant activities in which to engage despite the immediate desire to do very little, with the goal of lifting one’s mood (much like behavioral activation). The use of pleasant activities in response to feelings of anger is commonly included in anger management interventions (e.g., Sukhodolsky & Scahill, 2012), so this strategy was easily applied to Zara. However, unlike anger management interventions, which refer to this strategy as “distraction,” the application of this strategy for Zara and within the UP-C did not involve actively changing her internal state of anger, but rather encouraging her to engage in behaviors that were inconsistent with anger, as a way to experiment and test whether such behavior produced a natural decline in her feelings of anger. Zara identified a room in her house where she often liked to cool down alone while she was angry. After attempting this as an experiment, she found it helpful and continued to use this strategy throughout the course of treatment. Later in the sessions, Zara also found that spending 10 minutes on a positive activity, such as jumping on her trampoline, was also sufficient to allow her frustration to decrease without resorting to maladaptive emotional behaviors. During the parent component of the session, parents reviewed strategies for reinforcement (as an opposite parenting behavior to criticism), including token economies, sticker charts, nonverbal and verbal reinforcement, and appropriate prizes (e.g., picking a meal, several extra minutes of screen time, special one-on-one time). For Mrs. B, we encouraged her to implement a sticker chart

with weekly opportunities to win prizes and/or treats for staying calm at night when Zara wanted her mother’s company. Zara was also reinforced for using opposite actions in the evening when she would become scared (e.g., read a book for 5 minutes and see if this helps before calling for Mom) and when angry, such as spending alone time to cool off and removing herself from a situation. Mrs. B worked to provide immediate and specific praise for these behaviors. Although Mrs. B implemented a sticker chart for several weeks, she found that this reinforcement was neither immediate nor salient enough to encourage Zara to use opposite action. Realizing this, Mrs. B developed a system of more immediate and salient reinforcement that was built into Zara’s routine. For example, she reported that in one situation, Zara had an angry outburst and once she calmed down shortly after, Zara requested a different breakfast than what was being served. Realizing the opportunity for implementing a contingency, Mrs. B explained that Zara had not earned her choice of breakfast, but that if she used opposite action the next day, she could have her choice of meal. Reinforcement like this appeared to work better for encouraging Zara to use opposite action because the rewards were immediate. It was also important to encourage Mrs. B to identify behaviors she could praise, even in situations when Zara was engaging in unhelpful or inappropriate behaviors. For example, if Zara removed herself from a situation to yell in her room, rather than criticizing her strong emotional reaction, Mrs. B was encouraged to praise Zara for using an opposite action to cool down independently. The treatment focus then moved to physiological awareness. The children learned “body scanning,” in which they carefully scanned their bodies for physical sensations associated with emotion states, and learned to take an acceptance-oriented stance towards such sensations. To demonstrate this phenomenon, children engaged in interoceptive exposures during which they

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

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Table 3

CEMS-Child Pre- and Posttreatment Scores With Reliable Change Index CEMS-Child

Pre

Post

Change Score

Calculated RCI

Anger Inhibition Anger Dysregulation Anger Coping

1 2.33

1 0.67

0 1.67

.87 1.06 ⁎

1

2

1

0.83 ⁎

Note: CEMS = Children’s Emotion Management Scale, RCI = Reliable Change Index * Exceeded RCI

purposely elicited body feelings and monitored them as they decreased without intervention. The application of techniques like body scanning in the context of Zara’s anger was relatively straightforward, as it is quite similar to the strategies used in anger management protocols for developing physiological awareness (e.g., Sukhodolsky & Scahill, 2012). In Zara’s case, body scanning was framed as a strategy she could use to identify early on when she was feeling angry so that she could preemptively engage in more adaptive behaviors, such as opposite action, or so that she could practice maintaining a neutral, accepting stance, and allow her emotions and associated sensations to resolve without intervention. In conducting interoceptive exposures to teach the children to maintain a neutral stance towards physiological sensations, it was important to identify sensations that were unique to Zara. She reported that

her face often became warm and she clenched her fists when angry. As such, interoceptive exposures involved clenching her fists or clenching her jaw for a short period of time to mimic the sensations of anger. Parents also focused on expressing empathy during this session. Specifically, this discussion addressed how to express empathy in the context of encouraging the use of adaptive strategies for managing emotional situations. In Zara’s case, this was important because her emotional behavior was often frustrating and upsetting for Mrs. B, which made it particularly difficult to express empathy. Parents in the group were encouraged to label their children’s emotions and express that they understood why their child would feel that way in response to the trigger, and then suggest a strategy or skill the child could use to manage the situation. Mrs. B and the other group parents practiced these steps between sessions and recorded their experiences. Mrs. B reported that she had practiced empathy when Zara was feeling upset about being alone in her room. She reported that when she began by expressing empathy for Zara’s feelings, Zara was more willing to try using opposite action to manage her emotion. Look at My Thoughts (L Skill) The next phase of treatment established the foundation for cognitive techniques that followed. The children were introduced to Thinking Traps (in the adult literature, “cognitive distortions”) and encouraged to begin thinking flexibly about their automatic interpretations of various situations. Children began by discussing

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How much of a problem was this?

7 6

Handling her anger 5 4 3 2 1

Waking at night/sleeping alone

Having a hard time when people talk about her dad

0

Figure 1. Parent Top Problem RatingsNote: Zara and her mother could not attend sessions 9 and 12 in the group (content was made up at a later date) so Top Problem ratings could not be collected on these days. Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger

11

How much of a problem was this?

8 7 6

Handling my anger

5 4 3

Waking at night/sleeping alone

2 1

Having a hard time when people talk about dad

0

Figure 2. Child Top Problem RatingsNote: Zara and her mother could not attend sessions 9 and 12 in the group (content was made up at a later date) so Top Problem ratings could not be collected on these days.

this with nonemotional examples and practiced interpreting ambiguous images and situations in various ways. This type of flexible thinking lent itself readily to Zara’s anger concerns, as she often displayed a tendency towards hostile attributions. For example, when Zara’s mother would help her with homework, Zara frequently became angry when she was corrected. Zara’s reported Thinking Trap was, “she always thinks I’m wrong,” which understandably resulted in anger and frustration. Within the U Skill (described below), Zara was encouraged to think of alternative appraisals for her mother’s behavior, which might result in feeling less frustrated. In addition to introducing the concept of Thinking Traps to parents, this session also focused on the importance of consistency for encouraging desired behavior, the opposite parenting behavior to inconsistent reinforcement and punishment. Parents reviewed basic behavioral reinforcement and punishment principles, as well as the importance of maintaining consistency with these systems. Parents were encouraged to develop one or two behaviorally grounded rules to establish limits for behavior. In Zara’s case, these rules included keeping her hands to herself and using an indoor voice in the house. Furthermore, the use of effective commands was demonstrated by teaching the parents to deliver one calmly stated command at a time and give sufficient time for the child to comply. Finally, appropriate and effective response cost procedures were discussed. These strategies bolstered Mrs. B’s use of contingency management and allowed her to implement response costs in addition to

reinforcement for encouraging Zara to use self-regulation strategies when she was frustrated or anxious. Use Detective Thinking (U Skill) Once children were able to reliably identify Thinking Traps, they were introduced to cognitive reappraisal and problem-solving techniques (collectively referred to as Detective Thinking strategies in the manual). Cognitive reappraisal, which is referred to as “Stop, Slow, Go,” involved having children identify their Thinking Traps (Stop), reviewing the evidence for these cognitions (Slow), and identifying alternative coping thoughts (Go). Cognitive reappraisal proved useful for Zara’s anger, particularly when anticipating anger triggers to modify her hostile attributions. Zara was guided through the Stop, Slow, Go steps in order to determine the likelihood that others were acting with hostile intent and to identify alternative explanations for their behavior (e.g., “my mom is correcting me because she cares about how I do on my homework”). With the UP-C, we encouraged the children to use Detective Thinking skills prior to an anxiety-provoking situation so that they could more planfully engage in opposite action by facing the feared situation rather than avoiding. However, one of the central challenges children with anger and irritability face is their ability to anticipate these triggers (Lochman et al., 2012). Therefore, when applying these skills to Zara’s anger, it was helpful to implement these strategies post-hoc, once she had calmed down and was able to discuss the anger-triggering event.

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Grossman & Ehrenreich-May

12

Anger Inhibition

Anger Coping

Anger Dysregulation

14

12

Subscale Score

10

8

6

4

2

0

Figure 3. Child CEMS ratingsNote: CEMS = Children’s Emotion Management Scale; Zara and her mother could not attend sessions 9 and 12 in the group (content was made up at a later date) so data could not be collected on these days.

Detective Thinking tools were used in this way as a preventative strategy to facilitate more adaptive responses to triggers moving forward. Children then learned problem solving, in which they were presented with a series of steps for “Getting Unstuck,” beginning with identifying the problem, followed by openly listing possible solutions without judging them, evaluating the pros and cons of each of these solutions, and then selecting a solution to attempt. When demonstrating this skill, we emphasized the importance of thinking flexibly about solutions without negating any that seemed unreasonable. To illustrate this skill, therapists had the children use the steps to solve a nonemotional problem (e.g., a frog is stuck on a lily pad and wants to get to shore) and encouraged the group to identify solutions that seem both realistic and far-fetched. This type of problem-solving is consistent with many interventions for anger and aggression (e.g., Sukhodolsky & Scahill, 2012). When applying this strategy individually for Zara, we often discussed possible solutions for problems that made her angry. This was helpful for encouraging her to respond less angrily to others, especially by illustrating the cons of her angry behavior. Because it was challenging to have Zara identify more adaptive solutions in the heat of her anger, the skill was used preemptively to identify possible solutions for the problem of waking up in the middle of the night. Her typical response was to call for her mother, but she would

often become increasingly angry if her mother did not respond immediately. Problem-solving was used to identify alternative strategies that she could implement herself to help her get back to sleep. Given that Zara often found it anxiety provoking to go back to sleep without her mother, strategies were added gradually. She would begin by trying one strategy for several minutes before going to get her mother; as she progressed, strategies were then added to the list. Zara identified several solutions to the problem (such as, “read in bed for 15 minutes, listen to music, count sheep”), which were written on a list that she could keep on her nightstand. These solutions were attempted sequentially until she fell back to sleep; if she was not able to fall back to sleep she could go to get her mother. During this portion of treatment, parents discussed the opposite parenting behavior to overcontrol/overprotection by planning strategies for healthy independencegranting. Parents reviewed the importance of reinforcement for coping skills and independent behavior and were introduced to the concept of shaping independence. Parents identified areas for their children to develop more independence and steps to successively approximate this behavior. For Zara, this included getting ready for bed without her mother. This task was broken down into smaller steps (e.g., pick out clothes for school, brush teeth, wash face), which would be added on as independent tasks. In addition, parents discussed how

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger

Anger Inhibition

Anger Dysregulation

13

Anger Coping

14

12

Subscale Score

10

8

6

4

2

0

Fig. 4. Parent CEMS ratingsNote: CEMS = Children’s Emotion Management Scale; Zara and her mother could not attend sessions 9 and 12 in the group (content was made up at a later date) so data could not be collected on these days.

they could shape the use of Detective Thinking and Problem Solving using specific prompts and scaffolding when appropriate to support the eventual use of the skills independently. For example, Mrs. B was encouraged to prompt Zara to use Detective Thinking strategies before going to bed in the evening by reminding her of the strategy, and providing cues for steps as needed. These strategies also served to provide parents with an alternative response to children’s reassurance-seeking behavior: rather than providing direct reassurance, parents could prompt children to use adaptive cognitive strategies. Experience My Emotions (E Skill) Following the cognitive skills sessions, children learned present-moment and nonjudgmental awareness in preparation for exposure sessions. Present-moment awareness and the associated exercises allowed children to experience the “here and now” in a nonemotional context, which they could then begin to do in more emotional situations. This skill was followed by teaching nonjudgmental awareness—the concept of allowing oneself to experience emotions without feeling badly for doing so. Nonjudgmental and present-moment awareness are particularly important within the UP model; under this model, emotional disorders are thought of as resulting not from the emotions themselves, but from the way we respond to our emotions. In this module, the focus was on experiencing emotions and allowing them to decrease naturally without making an active effort to avoid or suppress

them. Given Zara’s anger and irritability, nonjudgmental and present-moment awareness were specifically framed as strategies for her to be present with her emotions without engaging in specific cognitive or behavioral responses to reduce these emotions, as she often did. She frequently engaged in unhelpful behaviors to quell her anger (such as kicking things, being destructive), but she was encouraged to take opposite action and not act on emotions when she had the urge to do so. Awareness skills were followed by situational emotion exposures, consistent with behavioral interventions for anxiety disorders. Parents first worked independently to identify a hierarchy during the parent sessions, then these ideas were shared with the children and a list of exposure targets (referred to as an Emotional Behaviors Form; EBF) was further fleshed out for each participant. In keeping with the UP model, these lists included a variety of exposures related to a range of emotional and behavioral reactions, which were broken down into hierarchies (called Emotion Ladders), as needed. Because not all of Zara’s emotional reactions were avoidance or escape-related, exposures were tailored to gradually expose her to a variety of emotional triggers and shape more adaptive behavioral responses. Thus, exposures related to both her separation anxiety and to her anger were conducted. Anger-related exposures included playing games with the therapist and the other children in which Zara would

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

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Grossman & Ehrenreich-May

lose and had to respond adaptively without becoming upset and quitting the game. Purposely making games difficult or unfair to elicit a frustration response was also a strategy used to practice frustration tolerance. Another example involved a mock classroom with a mock test that was graded in the class. To encourage the use of effective coping skills for anger, therapists engaged Zara in antecedent planning—identifying expected reactions to the exposure and selecting specific skills that Zara could use to effectively regulate her frustration. For particularly difficult exposures, practicing skills before entering the exposure (e.g., present moment awareness and body scanning) was helpful to remind her of the strategy so that she could more easily access it later. In addition, to provide simple reminders of skills during the exposure, therapists used key words and visuals. Furthermore, discussing what specific opposite behavior Zara would engage in was helpful to establish expectations for “successful” anger regulation. For example, if Zara got upset playing a game, it was important to establish the goal of the exposure was to continue playing the game (for some children with higher levels of dysregulation, the goal may simply be to stay in the room without shouting). These exposures served as opportunities for Zara to practice opposite actions, and they appeared to increase her confidence in her ability to respond calmly to previously upsetting triggers. To further enhance the use of opposite action, anger exposures were often coupled with proactive approaches, including problem-solving to facilitate Zara’s identifications of appropriate ways to address the issue at hand. For example, implementing the problem-solving steps after utilizing opposite action and mindful awareness during an unfair game, Zara identified a solution of politely expressing her feelings about the game being played unfairly. In coupling these strategies together, Zara was able to practice both opposite action skills and more proactive, solution-focused skills. In addition, situational exposures for separation anxiety involved visiting places in the community and, where appropriate, having her mother wait outside while Zara was accompanied by the therapist. While these did not appear to elicit as much anxiety as Zara experienced in the evenings when separated from her mother, this provided an opportunity to practice skills in context. Stay Healthy and Happy (S Skill) The final session involved reviewing the skills learned and the children’s accomplishments, as well as discussing relapse prevention with the families. Children reviewed all of the CLUES Skills and the strategies they had learned during therapy. In addition, the families discussed ways to maintain gains and continue to generalize the skills. This conversation centered on reminding children to “become

their own therapists.” They identified domains in which they still wished to make changes in their emotional behaviors, and identified strategies from therapy that they could use to reach these goals. The application of this session for Zara was important given that most of her gains in treatment became apparent towards the second half of the treatment. The discussion thus focused on the strategies learned in treatment, and when she could use these skills moving forward. Given her strong, automatic action tendencies toward intense emotional reactions, it was important to focus concretely on when and how adaptive emotion regulation skills could be employed. Clinical Outcomes Notable improvements were observed when Zara’s mother began implementing behavioral contingencies in the home, which largely occurred during the exposure phase of sessions. Though prior parent sessions had established a token system, this was implemented with varying levels of consistency early on and was not sufficiently reinforcing for Zara. After mixed success with this strategy, Zara’s mother insightfully began implementing behavioral contingencies that were suited to the family lifestyle. For example, making pancakes for breakfast became an earned privilege for appropriately managing Zara’s anger during the course of the day. In addition, Mrs. B began to better understand her own role in the behavioral patterns taking place, particularly when Zara would wake up during the night and quickly escalate to extreme anger. Here, Mrs. B often engaged in a discussion or argued with Zara to try to convince her to go back to bed, or she would give in and sleep with her for the remainder of the night. Mrs. B found it more effective to walk Zara back to her room silently, providing no additional attention. If Zara got up again, she would be walked back to her room again. These strategies, coupled with Zara’s own use of skills to regulate her strong emotions, appeared effective for the family. Overall, Zara’s separation anxiety symptoms also abated, and no further exposures were necessary. To examine changes quantitatively, the Reliable Change Index was calculated using the methods described in Minami and Brown (2007). The Reliable Change Index (RCI) is a statistic used to determine whether an individual’s score on a measure is significantly different at two time points based on the measure’s reliability. The RCI produces a standardized score that represents the individual’s change score divided by the standard error of the difference between the two scores for the measure being used (Horswill, 2009). Both the Coping and Dysregulation subscales for the child-report of the CEMS exceeded the Reliable Change Index (RCI),

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

Using The Unified Protocol For Anger indicating that, with 95% confidence, the change in scores was not due to chance alone. The overall changes are presented in Table 3. The values used for calculating the RCI were extracted from Suveg et al. (2009). As no parent-report scores were collected in Suveg et al. (2009), RCI for Zara’s mother could not be calculated. In summary, Zara’s case demonstrates adherent use of the UP-C applied in the context of anger and angerrelated emotional behaviors in a child diagnosed with anxiety and oppositionality. Specifically, this child presented with a history of separation concerns and frequent, intense episodes of irritability and anger that occurred in the context of anxiety triggers and nonanxiety triggers. Through a transdiagnostic approach with appropriate parent involvement, Zara learned effective emotion management skills and ways to modify her previously automatic, maladaptive avoidance and approach-oriented action tendencies. Over the course of treatment, both Zara and her mother reported notable decreases on various symptom measures. The ratings of Top Problems by the reports of both Zara and her mother decreased substantially, and treatment gains were reflected in her scores on the CEMS. Figs. 1 and 2 demonstrate decreases in Top Problems rated by the child and the parent, and Figs. 3 and 4 reflect changes in the child and parent ratings of the CEMS subscales. On the CEMS Anger Coping subscale, items are coded such that higher scores indicate more effective coping. Conclusion Some research suggests that treatments for externalizing disorders may result in decreases in symptoms of cooccurring internalizing disorders (Lochman, Powell, Boxmeyer, Ford, & Minney, 2013). Indeed, many programs that treat anger and aggression in youth involve strategies that may be applied to emotional disorders. For example, one common strategy used to treat externalizing symptoms is contingency management, which can be applied to a range of behavioral concerns to produce more desired behaviors through positive reinforcement (e.g., approach behaviors in the case of emotional disorders, self-regulation in the case of excessive anger/irritability). Similarly, developing emotional awareness is a key component in many protocols to treat anger, and is often involved in cognitive-behavioral therapy for anxiety disorders. Teaching problem-solving skills is a common feature of treatments for anger and aggression, but is also frequently found in treatments for anxiety disorders (e.g., Kendall & Hedtke, 2006; Lochman et al., 2013; Lochman, Wells, & Lenhart, 2008). Importantly, such features are also included in the UP-A and UP-C, as described in this case example. However, the UP is unique in its focus on emotions, more broadly,

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and may, therefore, be appropriate for application to children with internalizing disorders who present with anger and irritability, as such symptoms may present differently among this population. The application of the UP-C, an emotion-focused transdiagnostic approach for treating anger in children with emotional disorders and anger-related symptoms, demonstrated efficacy in this case example. With careful case conceptualization and thorough understanding of the theory underlying UP, the treatment was easily applied without compromising fidelity to the manual. This particular case example demonstrates the tailoring of the UP-C within its existent structure for cases where irritability may be a presenting concern. Other recent work adapting the UP-C structure for children with primary externalizing concerns has also demonstrated promise (Malmberg, Kennedy, Holzman, and Ehrenreich-May, in press). Specifically, the intervention was shortened to 10 session and delivered to children that all presented with externalizing concerns (as opposed to the current case example who participated in a group of children with primary emotional disorder concerns). Modifications to the UP-C for externalizing problems included weekly parent-child activities to practice frustration tolerance (e.g., solving a difficult puzzle, talking about an ongoing family conflict, etc.), a greater emphasis on anger-related examples within child curriculum, and the addition of a cognitive distortion to capture hostile attribution bias (e.g., “Out to Get Me Owen”). Parent content was also modified to focus more so on emotional parenting behaviors as they apply to children with irritability, and included a greater emphasis on the program’s behavior management strategies (Malmberg et al., in press). Given the increasing evidence for the presence of anger and irritability in children with emotional disorders (Caporino et al., 2015; Cornacchio et al., 2016; Knox, King, Hanna, Logan, & Ghaziuddin, 2000; Roy et al., 2013; Suveg & Zeman, 2004), appropriate and feasible interventions are needed to target such symptoms. Interventions like the UP-C and other UP manuals are ideal because they do not require training in multiple treatments, and are sufficiently flexible to address a range of concerns. The UP-C presents an appropriate alternative to single-disorder treatments for anxiety, and anger/ aggression-focused treatments, which may lack the flexibility to address withdrawal and avoidance behaviors that present in anxiety disorders. Indeed, anger and irritability that arise from anxiety and depression may require a unique approach to targeting both anger behaviors and withdrawal behaviors, by addressing both emotion regulation (for anger) and helpful approach behavior (for anxiety/depression). An advantage of treatments like the UP-C, as compared to other

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004

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approaches that may be transdiagnostic, is this underlying unified theory that can guide clinicians in flexibly using materials across a wide range of emotion targets. In fact, the UP-C manual very purposely includes examples of anger, sadness and fear/worry for most treatment techniques described to facilitate this flexible application of the materials. Further research is needed to establish whether the UP-C is superior to other single-disorder treatments or transdiagnostic approaches that may encompass both anger and emotional disorder symptoms. At present, however, the UP-C represents a promising approach for youth who present with emotional disorders and concurrent anger regulation difficulties.

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the public, commercial, or not-for-profit sectors. The authors declare that there are no conflicts of interest. Address correspondence to Rebecca A. Grossman, University of Miami, Department of Psychology, 3665 Ponce De Leon Blvd, Coral Gables, FL 33133; e-mail: [email protected].

Received: May 11, 2018 Accepted: May 26, 2019 Available online xxxx

Please cite this article as: Grossman & Ehrenreich-May, Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability, (2019), https://doi.org/10.1016/j.cbpra.2019.05.004