The Unified Protocols for Children and Adolescents in Partial Hospitalization: Using Implementation Science Frameworks to Guide Adaptation

Partial hospitalization programs (PHPs) and other acute mental health treatment programs, which are becoming increasingly common, may help divert children and adolescents from inpatient psychiatric care and provide a concentrated dose of intervention to individuals living in low-resource areas. However, there have been relatively few examinations of the effectiveness of PHPs in addressing emotional concerns (e.g., anxiety, depression, irritability) and functional impairment in youth. Further, evidence-based treatments originally designed for delivery in an outpatient weekly format may require significant adaptation to be appropriate for delivery in acute mental health settings, which differ significantly from weekly outpatient care in program structure, patient acuity, and staffing. In this intervention development and adaptation report, we present the rationale for adapting a transdiagnostic approach to treating emotional disorders—the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A)—for a hospital-based, general psychiatric partial hospitalization program. We use implementation science frameworks to describe our iterative approach to treatment adaptation and testing and to describe in detail proactive, planned adaptations to the UP-C/A for partial hospitalization that occurred prior to initial implementation and pilot testing. Three case examples (child, preadolescent, adolescent) are presented to illustrate how a transdiagnostic approach to care such as the UP-C/A can be used intensively in an acute mental health setting to address emotional and behavioral concerns, including safety.     

Development and Application of an Innovative Transdiagnostic Treatment Approach for Pediatric Irritability

Recent work has drawn attention to the previously underrecognized role that irritability plays in childhood psychopathology. Despite increased recognition of the clinical importance of pediatric irritability as a transdiagnostic symptom dimension, there is a lack of evidence-based treatments for this population that simultaneously and equitably addresses both child and contextual (e.g., parental) factors implicated in the development and maintenance of associated emotional and behavioral difficulties. In the current pilot study, we adapted the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C) for the treatment of pediatric irritability in a sample of 19 children (ages 8 to 12) with primary presenting concerns of irritability and/or disruptive behaviors. Results supported the feasibility and acceptability of this treatment and provided preliminary evidence that such an approach may yield improved outcomes for symptoms of pediatric irritability and disruptive behaviors. Implications of these findings for future research and clinical interventions for pediatric irritability are discussed.     

Development and Implementation of a Transdiagnostic,Stepped-Care Approach to Treating Emotional Disorders in Children via Telehealth

Stepped-care interventions may increase the accessibility of evidence-based treatments but remain relatively underexplored in the child mental health literature. Further, while the feasibility and efficacy of stepped-care interventions have been examined for specific diagnoses or classes or disorders, transdiagnostic stepped-care interventions have not yet been developed. We discuss the development and initial implementation of a transdiagnostic approach to emotional disorders using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). A case series is presented to illustrate the delivery of UP-C stepped care (UPC-SC) via telehealth, using a collaborative decision-making process to inform step-up/step-down decisions. Lessons learned are discussed to guide refinements of UPC-SC and inform a larger trial.     

Targeting Common Factors Across Anxiety and Depression Using the Unified Protocol for the Treatment of Emotional Disorders in Adolescents

Clinical approaches to mood and anxiety disorders in children and adolescents have historically been confined to either diagnosis- [e.g., for obsessive–compulsive disorder vs. generalized anxiety disorder (GAD), etc.] or domain-specific (e.g., for anxiety disorders vs. depressive disorders) treatments. However, as conceptualizations of mental illness shift towards a more dimensional model [e.g., the recent Research Domain Criteria (RDoC) from the National Institutes of Health], transdiagnostic treatments, such as the unified protocol for the treatment of emotional disorders in adolescents (UP-A; Ehrenreich et al. in Child Fam Behav Ther 31(1):20–37, 2008), are gaining support in the empirical literature. This paper reviews the common treatment targets across three emotional disorders commonly found in adolescence: GAD, social anxiety disorder, and major depressive disorder. In particular, similarities and differences across potential treatment mechanisms, including cognitive and information processing deficits, problem-solving difficulties, and avoidance strategies are examined. Finally, the case of 17-year-old “Andrea” is presented to demonstrate how transdiagnostic approaches like the UP-A can be effective in treating a range of emotional disorders in youth.     

Changes in Risk Factors During the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This study aimed to assess whether changes in potentially modifiable risk factors associated with the construct of neuroticism and common to emotional disorders (i.e., poor distress tolerance and heightened avoidance) occur in concordance with the administration of different treatment components of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and with reductions in emotional disorder symptoms (i.e., anxiety and depressive symptoms) overall. Using single-case analytic strategies, including multiple-baseline design and modeling techniques, the authors treated 8 adolescents with emotional disorder diagnoses and evaluated trajectories of change in distress tolerance and experiential avoidance as well as in the sequencing of such change in regard to change in anxiety and depressive symptoms. Clinical outcomes were favorable based on parent, adolescent, and clinician-rated measures. Treatment-based change was demonstrated, at both group and individual levels, and at expected points in treatment, in regard to facets of neuroticism. Overall, self-reported change in experiential avoidance and distress tolerance tended to occur simultaneously to reductions in emotional disorder symptoms. This study helps to clarify the course of expected change in variables believed to be common among a range of emotional disorders during a transdiagnostic treatment and provides initial information regarding tailoring the UP-A for individuals with different clinical profiles.     

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called “lumpers” and “splitters”—those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper “Toward a Unified Treatment for Emotional Disorders” reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.     

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) Adapted as a School-Based Anxiety and Depression Prevention Program: An Initial Cluster Randomized Wait-List-Controlled Trial

Anxiety and depression are common debilitating conditions that show high comorbidity rates in adolescence. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich-May et al., 2018) is one of the few existing resources aimed at applying transdiagnostic treatment principles across the core dysfunctions implicated in the development of both anxiety and depression using a single protocol. This is the first known controlled study to examine the efficacy of the UP-A adapted as a nine-session universal preventive intervention program delivered in a school setting. A total of 151 students (mean age: 15.05) participated in this randomized wait-list-controlled trial conducted in Madrid, Spain. An unexpected decline in anxiety and depression levels from pre- to posttreatment and follow-up was found in both groups (p = .009, d = –0.22), and overall differences between conditions did not reach significance. Exploratory analyses of baseline emotional symptom severity as a potential predictor trended toward a significantly greater decrease in symptoms of depression for those with greater baseline emotional symptoms in the UP-A group compared to the wait-list-control group. Future trials with larger samples are justified to estimate the effect of the UP-A adapted as a selective prevention program for anxiety and depression.     

Exposure-Based Cognitive-Behavioral Therapy for Disruptive Mood Dysregulation Disorder: An Evidence-Based Case Study

Severe, chronic irritability is one of the most frequently reported problems in youth referred for psychiatric care. Irritability predicts adult depressive and anxiety disorders, and long-term impairment. Reflecting this pressing public health need, severe, chronic, and impairing irritability is now codified by the DSM-5 diagnosis of disruptive mood dysregulation disorder (DMDD). Since DMDD has only recently been added as its own nosological class, efficacious treatments that specifically target severe irritability as it presents in DMDD are still being developed. In a recent pilot study, we described the general concept of exposure-based cognitive-behavioral therapy (CBT) for irritability. This mechanism-driven treatment is based on our pathophysiological model of irritability that postulates two underlying mechanisms, which potentiate each other: (1) heightened reactivity to frustrative nonreward, and (2) aberrant approach responses to threat. In this case report, we describe and illustrate the specific therapeutic techniques used to address severe irritability in an 11-year-old boy with a primary diagnosis of DMDD. Specific techniques within this CBT include motivational interviewing to build commitment and target oppositionality; creation of an anger hierarchy; in-session controlled, gradual exposure; and parent training focusing on contingency management to counteract the instrumental learning deficits in irritable youth. Parents learn to tolerate their own emotional responses to their youth’s irritability (e.g., parents engage in their own exposure) and increase their adaptive contingencies for their youth’s behavior (e.g., withdraw attention during unwanted behavior, praise desirable behavior). Future directions in the context of this CBT, such as leveraging technology, computational modeling, and pathophysiological targets, are discussed.     

Irritability as a Transdiagnostic Vulnerability Trait:Current Issues and Future Directions

In recent years, irritability has received increasing attention among mental health professionals given its transdiagnostic associations with diverse forms of psychopathology. In contrast to other emotional states and traits, however, literature addressing associations between irritability and related temperament and personality constructs is limited. In addition, those who study irritability have diverse perspectives on its neurobiological substrates. In this comment, we situate irritability in the literatures on child temperament and adult personality, and describe a model in which irritability derives from low tonic dopamine (DA) levels and low phasic DA reactivity in subcortical neural structures implicated in appetitive responding. We note that different findings often emerge in neuroimaging studies when irritability is assessed in circumscribed diagnostic groups versus representative samples. We conclude with directions for future research, and propose that more authors use hierarchical Bayesian modeling, which captures functional dependencies between irritability and other dispositional traits (e.g., trait anxiety) that standard regression models are insensitive too. Treatment implications are also considered.     

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents’ mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.     

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.     

Anger and Irritability Symptoms among Youth with ODD: Cross-Informant Versus Source-Exclusive Syndromes

We examined differences in co-occurring psychological symptoms and background characteristics among clinically referred youth with oppositional defiant disorder (ODD) with and without anger/irritability symptoms (AIS) according to either parent or teacher (source-exclusive) and both informants (cross-informant), youth with noncompliant symptoms (NS) of ODD, and non-ODD clinic controls. Parents and teachers evaluated 1127 youth (ages 6-18) with a DSM-IV-referenced rating scale to assess ODD and co-occurring psychological symptoms. Parents also completed a background questionnaire (demographic, developmental, treatment, relationship, and academic characteristics) and teachers rated school functioning. Source-exclusive AIS groups were associated with different clinical features, and there was some evidence that cross-informant youth had more mental health concerns than source-exclusive groups. Findings varied to some extent among older (12-18?years) versus younger (6-11?years) youth. In general, the NS group (youth without AIS) was the most similar to clinic controls. AIS and NS are likely candidates for component phenotypes in ODD and continued research into their pathogenesis may have important implications for nosology, etiology, and intervention.     

The Clinician Affective Reactivity Index: Validity and Reliability of a Clinician-Rated Assessment of Irritability

Irritability is impairing in youth and is the core feature of disruptive mood dysregulation disorder (DMDD). Currently, there are no established clinician-rated instruments to assess irritability in pediatric research and clinical settings. Clinician-rated measures ensure consistency of assessment across patients and are important specifically for treatment research. Here, we present data on the psychometric properties of the Clinician Affective Reactivity Index (CL-ARI), the first semistructured interview focused on pediatric irritability. The CL-ARI was administered to a transdiagnostic sample of 98 youth (M age = 12.66, SD = 2.47; 41% female). With respect to convergent validity, CL-ARI scores were (a) significantly higher for youth with DMDD than for any other diagnostic group, and (b) showed uniquely strong associations with other clinician-, parent-, and youth-report measures of irritability compared to measures of related constructs, such as anxiety. The three subscales of the CL-ARI (temper outbursts, irritable mood, impairment) showed excellent internal consistency. Test-retest reliability of the CL-ARI was adequate. These data support that irritability can be feasibly, validly, and reliably assessed by clinicians using the CL-ARI. A validated, gold-standard assessment of pediatric irritability is critical in advancing research and treatment efforts.     

Contextual Adaptation of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Victims of the Armed Conflict in Colombia: A Case Study

The delivery of a contextually adapted version of the Unified Protocol for transdiagnostic treatment of emotional disorders is illustrated through a case study of an internally displaced female victim of armed conflict in Colombia. A detailed account of how her history of continuous traumatic events and her forced displacement resulted in multiple emotional disorders and behaviors which hindered her ability to react to daily stressors illustrates the particular conditions of individuals exposed to extreme violence. Emphasis is placed on how her culture and context required adaptations of evidence-based interventions. The contextually adapted UP (CXA-UP) is described in “slow-motion,” through a session-by-session account of the procedure along with the specific changes in each module. Outcome measures showed four positive diagnoses at pretreatment, but none at posttreatment, 3-month, or 2-year follow-up. Implications for global applications with individuals in similar contexts and for widening access to such interventions are discussed.     

Dimensional Assessment of Emotional Disorder Outcomes in Transdiagnostic Treatment: A Clinical Case Study

Current classification systems for mental disorders emphasize categorical assessment. In the domain of emotional disorders, this is inconsistent with a growing consensus that anxiety, depressive, and related disorders are best conceptualized as variations on shared underlying processes, chiefly heightened negative affect, and aversion to unwanted emotional experiences. Dimensional assessment of transdiagnostic emotional disorder constructs offers advantages for clinical and research applications, including increased parsimony and improved validity, yet there are drawbacks to many dimensional assessment systems for emotional disorders. The case presented in this paper illustrates the potential clinical utility of a new self-report instrument—the Multidimensional Emotional Disorders Inventory (MEDI)—which assesses nine dimensions characteristic of emotional disorders. MEDI scores for a highly comorbid patient are examined over the course of transdiagnostic emotion-focused cognitive-behavioral treatment. At baseline, midtreatment, and posttreatment, the MEDI offered information above and beyond DSM categorical assessment, including detection of subclinical symptoms and symptom change, while remaining parsimonious. Implications for possible use as a treatment planning instrument, integration with categorical assessment, and future research directions are discussed.     

The Internal Structure of the Aberrant Behavior Checklist Irritability Subscale: Implications for Studies of Irritability in Treatment-Seeking Youth With Autism Spectrum Disorders

Given the prominence of the Aberrant Behavior Checklist (ABC), Irritability Subscale (ABC-I), in treatment outcome studies, we conducted a critical examination of its internal consistency and relationship to other measures of irritability in 758 psychiatrically hospitalized youth with autism spectrum disorder. In exploratory and confirmation samples, we conducted factor and bifactor analyses to describe the internal structure of the ABC-I. Our results suggest that the ABC-I roughly represents a unidimensional construct of irritability, as indicated by a general factor in bifactor analysis. In addition to irritability, subordinate factors are presented that represent tantrums, verbal outbursts, self-harm, and negative affect. Notably, self-harm items explain a large proportion of variance independent of irritability. Therefore, their contribution in analyses of treatment effects should be considered. Further study or revision of the ABC-I may improve convergent validity with transdiagnostic formulations of irritability as well as prevent confound from self-harm in treatment studies for irritability in ASD     

The dreaming mind-brain: a Jungian perspective

In this paper I discuss the nature and role of dream and the dreaming process in Jungian clinical practice in the light of neuroscience. Insights from contemporary neuroscience support rather than contest Jung's view that emotional truth, not censorship or disguise, underpins the dreaming process. I use clinical material to illustrate how work with dreams within the total interactive experience of the analytic dyad enables the development of the emotional scaffolding necessary for the development of 'mind'. Large scale evidence-based research reveals that dreaming is caused by brain activity during sleep that is both biochemically and regionally different from that of waking states. Recent imaging studies confirm that dreams are the mind's vehicle for the processing of emotional states of being, particularly the fear, anxiety, anger or elation that often figure prominently. Dream sleep is understood as also being the guardian of memory, playing a part in forgetting, encoding and affective organization of memory. In the clinical section of the paper I let a series of dreams speak for themselves, revealing the emotionally salient concerns of the dreamer, weaving past and present, transference and reality together in a way that demonstrates the healthy attempt of the brain-mind to come to terms with difficult emotional experience from the past. The dreams become dreamable as part of the meaning-making process of analysis.     

Emotion Regulation in Youth with Emotional Disorders: Implications for a Unified Treatment Approach

Given the relationship between internalizing disorders and deficits in emotion regulation in youth, the emotion science literature has suggested several avenues for increasing the efficacy of interventions for youth presenting with anxiety and depression. These possibilities include the identification and addition of emotion-regulation skills to existing treatment packages and broadening the scope of those emotions addressed in cognitive-behavioral treatments. Current emotion-focused interventions designed to meet one or both of these goals are discussed, and the developmental influences relevant to the selection of emotion-focused treatment goals are explored using the framework of a modal model of emotion regulation. These various lines of evidence are woven together to support the utility of a novel emotion-focused, cognitive-behavioral intervention, the Unified Protocol for the Treatment of Emotional Disorders in Youth, a transdiagnostic treatment protocol that aims to treat the range of emotional disorders (i.e., anxiety and depression) simultaneously. Avenues for future directions in treatment outcome and assessment of emotion regulation are also discussed.     

Calibrating for Comorbidity: Clinical Decision-Making in Youth Depression and Anxiety

Comorbidity in clinical youth populations is more the rule than the exception, yet few established guidelines exist to help practicing clinicians manage complex diagnostic profiles. The current paper reviews efforts within the treatment development literature to handle comorbidity in depressed and anxious children and adolescents, including single-target, modular-based, and transdiagnostic interventions. Two case studies are presented to describe how comorbid anxiety and depression are managed within two different evidence-based single-target interventions. A third case is presented to introduce a novel individual behavioral activation therapy (IBAT) designed to address co-occurring depression and anxiety by targeting a single maintaining mechanism (avoidance) that underlies both disorders. Implications for clinical decision-making (assessing complex clinical profiles in practice, prioritizing treatment goals, selecting interventions from a broad evidence base) are discussed.