Behavior Therapy for Irritability in Autism (BTIA)

This is a clinical trial of a novel intervention, Behavioral Therapy for Irritability and Aggression (BTIA), for adolescents on the autism spectrum. The main goals of BTIA are to help adolescents develop emotion regulation skills to handle frustration and to strengthen skills for navigating the challenging and diverse experiences associated with the transition to adulthood. The study will test whether BTIA can be helpful to adolescents on the autism spectrum and to their families.

This is a randomized controlled study of BTIA versus a supportive therapy control condition in 126 adolescents (ages 12 to 18 years) with a diagnosis of autism spectrum disorder and significant levels of disruptive behaviors such as aggression, anger outbursts, and oppositional behavior. BTIA consists of 15 ninety-minute weekly sessions that will be conducted with the teens and their parents by therapists using a structured, detailed manual. The effects of BTIA on the reduction of behavioral problems will be rated by an experienced clinician who does not know which treatment each participant is receiving (a "blinded" evaluator). Study participants will receive a thorough diagnostic assessment of autism spectrum disorder and other forms of psychopathology that may co-occur with ASD. In addition to testing the effects of BTIA on disruptive behavior, the changes in adaptive functioning, or children's ability to function competently in their everyday environment, will be examined before and after treatment.

Autism Spectrum Disorder, Irritability, Disruptive Behavior, Anger, Aggression, Asperger Syndrome, Pervasive Developmental Disorder

autism, adolescents, behavior therapy, treatment, disruptive behavior, irritability, anger, aggression

This is randomized controlled trial of behavior therapy for irritability versus a supportive therapy control condition

Primary outcomes will be assessed by an independent evaluator who will be "blinded" to subject's treatment assignment

BTIA consists of 15 ninety-minute weekly sessions that will be conducted with the teens and their parents by experienced therapists using a structured, detailed manual.

PST consist of 15 weekly, ninety-minute sessions focused on learning about and discussing issues of diagnosis, treatment and educational services with an experienced therapist could be helpful to children on the autism spectrum and their families.

The child-focused components of BTIA are organized in modules dedicated to emotion regulation, problem solving and practice of planned steps to prevent or resolve conflicts. Each session contains a set of six to seven goals, and each goal contains a menu of techniques and activities that can be used to attain this goal. In order to administer the treatment in a flexible yet reliable manner, the therapist works collaboratively with the child and his or her parents to select activities that are perceived as relevant for attaining the session's goal. The parent-focused components of BTIA include include education about the effects of antecedents and consequences on disruptive behavior, developing strategies for reducing or altering antecedent events that may lead to disruptive reactions and helping parents to use reinforcement of competent and calm responses in potentially frustrating situations.

Each PST session will start with a review of events of the past week and include queries of topics such as school, interests, hobbies, and family with an overarching goal of enhancing subjective well-being. A major objective is to enables the participant to discuss his or her concerns with a therapist toward a goal of enhancing overall psychological wellbeing. Education about autism diagnosis and services is also provided to families as part of PST.

Modified Overt Aggression Scale is a 16-item scale that reflects the frequency and severity of incidents of aggressive behavior. Scores can range from 0 (minimum) to 300 (maximum) with higher scores reflecting worse outcome.

Modified Overt Aggression Scale is a 16-item scale that reflects the frequency and severity of incidents of aggressive behavior. Scores can range from 0 (minimum) to 300 (maximum) with higher scores reflecting worse outcome.

Modified Overt Aggression Scale is a 16-item scale that reflects the frequency and severity of incidents of aggressive behavior. Scores can range from 0 (minimum) to 300 (maximum) with higher scores reflecting worse outcome.

Modified Overt Aggression Scale is a 16-item scale that reflects the frequency and severity of incidents of aggressive behavior. Scores can range from 0 (minimum) to 300 (maximum) with higher scores reflecting worse outcome.

The Clinical Global Impression - Improvement Score assigned by an independent evaluator (IE) who will be blind to treatment assignment is the categorical primary outcome measure of aggressive behavior. The CGI-I reflects the IE's assessment of overall change from baseline rated on a scale from 1 to 7 where 1 is very much improved, 2 is much improved, 3 is minimally improved, 4 is no change, 5 is minimally worse, 6 is much worth, and 7 is very much worse. Higher scores reflect worse outcome. By convention, ratings of very much improved (1) or much improved (2) define positive response; all other scores are classified as a negative response.

The Clinical Global Impression - Improvement Score assigned by an independent evaluator (IE) who will be blind to treatment assignment is the categorical primary outcome measure of aggressive behavior. The CGI-I reflects the IE's assessment of overall change from baseline rated on a scale from 1 to 7 where 1 is very much improved, 2 is much improved, 3 is minimally improved, 4 is no change, 5 is minimally worse, 6 is much worth, and 7 is very much worse. Higher scores reflect worse outcome. By convention, ratings of very much improved (1) or much improved (2) define positive response; all other scores are classified as a negative response.

The Clinical Global Impression - Improvement Score assigned by an independent evaluator (IE) who will be blind to treatment assignment is the categorical primary outcome measure of aggressive behavior. The CGI-I reflects the IE's assessment of overall change from baseline rated on a scale from 1 to 7 where 1 is very much improved, 2 is much improved, 3 is minimally improved, 4 is no change, 5 is minimally worse, 6 is much worth, and 7 is very much worse. Higher scores reflect worse outcome. By convention, ratings of very much improved (1) or much improved (2) define positive response; all other scores are classified as a negative response.

The Clinical Global Impression - Improvement Score assigned by an independent evaluator (IE) who will be blind to treatment assignment is the categorical primary outcome measure of aggressive behavior. The CGI-I reflects the IE's assessment of overall change from baseline rated on a scale from 1 to 7 where 1 is very much improved, 2 is much improved, 3 is minimally improved, 4 is no change, 5 is minimally worse, 6 is much worth, and 7 is very much worse. Higher scores reflect worse outcome. By convention, ratings of very much improved (1) or much improved (2) define positive response; all other scores are classified as a negative response.

The 15-item Irritability subscale includes questions about aggression, tantrums, agitation, and unstable mood that are rated on a 4-point scale with the following anchor points: 0 = not at all a problem; 1 = the behavior is a problem but slight in degree; 2 = the problem is moderately serious; 3 = the problem is severe in degree. The total Irritability subscale score ranges from 0 to 45, with higher scores indicating greater severity.

The 15-item Irritability subscale includes questions about aggression, tantrums, agitation, and unstable mood that are rated on a 4-point scale with the following anchor points: 0 = not at all a problem; 1 = the behavior is a problem but slight in degree; 2 = the problem is moderately serious; 3 = the problem is severe in degree. The total Irritability subscale score ranges from 0 to 45, with higher scores indicating greater severity.

The 15-item Irritability subscale includes questions about aggression, tantrums, agitation, and unstable mood that are rated on a 4-point scale with the following anchor points: 0 = not at all a problem; 1 = the behavior is a problem but slight in degree; 2 = the problem is moderately serious; 3 = the problem is severe in degree. The total Irritability subscale score ranges from 0 to 45, with higher scores indicating greater severity.

The 15-item Irritability subscale includes questions about aggression, tantrums, agitation, and unstable mood that are rated on a 4-point scale with the following anchor points: 0 = not at all a problem; 1 = the behavior is a problem but slight in degree; 2 = the problem is moderately serious; 3 = the problem is severe in degree. The total Irritability subscale score ranges from 0 to 45, with higher scores indicating greater severity.

Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) is a measure of competence in communication, daily living skills, and socialization which is administered in a semi-structured parent interview format. Items assess the individual's behavior in these domains and are rated according to the frequency with which behaviors are performed without help or prompting (i.e., "Never," "Sometimes" or "Usually"). The raw scores are converted to standard scores (mean = 100, SD = 15; range 40 to 160), and higher scores indicate better adaptive functioning.

Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) is a measure of competence in communication, daily living skills, and socialization which is administered in a semi-structured parent interview format. Items assess the individual's behavior in these domains and are rated according to the frequency with which behaviors are performed without help or prompting (i.e., "Never," "Sometimes" or "Usually"). The raw scores are converted to standard scores (mean = 100, SD = 15; range 40 to 160), and higher scores indicate better adaptive functioning.

Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) is a measure of competence in communication, daily living skills, and socialization which is administered in a semi-structured parent interview format. Items assess the individual's behavior in these domains and are rated according to the frequency with which behaviors are performed without help or prompting (i.e., "Never," "Sometimes" or "Usually"). The raw scores are converted to standard scores (mean = 100, SD = 15; range 40 to 160), and higher scores indicate better adaptive functioning.

Affective Reactivity Index (ARI) is an 7-item measure of anger and irritability in children and adolescents which is reliable in ASD. Items are scored of a 0, 1 or 3 scale and first 6 items are summed for a total score, with a possible range from 0 to 12, higher scores reflecting greater levels of irritability

Affective Reactivity Index (ARI) is an 7-item measure of anger and irritability in children and adolescents which is reliable in ASD. Items are scored of a 0, 1 or 3 scale and first 6 items are summed for a total score, with a possible range from 0 to 12, higher scores reflecting greater levels of irritability

Affective Reactivity Index (ARI) is an 7-item measure of anger and irritability in children and adolescents which is reliable in ASD. Items are scored of a 0, 1 or 3 scale and first 6 items are summed for a total score, with a possible range from 0 to 12, higher scores reflecting greater levels of irritability

Affective Reactivity Index (ARI) is an 7-item measure of anger and irritability in children and adolescents which is reliable in ASD. Items are scored of a 0, 1 or 3 scale and first 6 items are summed for a total score, with a possible range from 0 to 12, higher scores reflecting greater levels of irritability

Social Responsiveness Scale-2 (SRS-2) is a 65-item, parent-report scale that measures social disability. Items assess the individual's social awareness, social cognition, social communication, social motivation, and restricted interest and repetitive behaviors on a scale from 0 to 3. The raw scores are converted to T-scores (mean = 50, SD = 10; range 30 to 90), and higher scores indicate greater impairment.

Social Responsiveness Scale-2 (SRS-2) is a 65-item, parent-report scale that measures social disability. Items assess the individual's social awareness, social cognition, social communication, social motivation, and restricted interest and repetitive behaviors on a scale from 0 to 3. The raw scores are converted to T-scores (mean = 50, SD = 10; range 30 to 90), and higher scores indicate greater impairment.

Social Responsiveness Scale-2 (SRS-2) is a 65-item, parent-report scale that measures social disability. Items assess the individual's social awareness, social cognition, social communication, social motivation, and restricted interest and repetitive behaviors on a scale from 0 to 3. The raw scores are converted to T-scores (mean = 50, SD = 10; range 30 to 90), and higher scores indicate greater impairment.

Social Responsiveness Scale-2 (SRS-2) is a 65-item, parent-report scale that measures social disability. Items assess the individual's social awareness, social cognition, social communication, social motivation, and restricted interest and repetitive behaviors on a scale from 0 to 3. The raw scores are converted to T-scores (mean = 50, SD = 10; range 30 to 90), and higher scores indicate greater impairment.

Inclusion Criteria: Boys and girls, ages 12 to 18 years inclusive Diagnosis of autism spectrum disorder Presence of disruptive behaviors such as irritability and anger outbursts No planned changes in the intensity of current treatment(s) Medication free or on stable medication Sufficient language for participation in verbal therapy Lives within driving distance from New Haven, CT Exclusion Criteria: Presence of a medical condition that would interfere with participation in the study Presence of a current psychiatric disorder that requires immediate clinical attention

Research data from this study will be shared via the National Database for Autism Research and NIH Data Repositories (https://nda.nih.gov/) consistent with the Yale University Policy. The data management for this study will be conducted using the OnCore system at YCCI (https://medicine.yale.edu/ycci/oncore/), which enables translation of data to de-identified data sets that can be placed online using GUID technology as specified in Federal guidelines. At the time of permission/consent/assent, participants and their parents will be informed of the data-sharing plan. Raw data generated by the project will be quality-certified by our research team (including fidelity to research procedures, proper file format, artifact removal, and de-identifying, resulting in artifact-free raw data) prior to submission to NDAR for usability. Consistent with the NDAR data sharing policy, data will be submitted, at the individual level, on all enrolled subjects.

Analyzed data will be submitted at the time of publication, and publications resulting from these data will be associated with NDAR entries using the NDAR Study Feature.

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Henriksen M, Skrove M, Hoftun GB, Sund ER, Lydersen S, Tseng WL, Sukhodolsky DG. Developmental Course and Risk Factors of Physical Aggression in Late Adolescence. Child Psychiatry Hum Dev. 2021 Aug;52(4):628-639. doi: 10.1007/s10578-020-01049-7.

Kalvin CB, Gladstone TR, Jordan R, Rowley S, Marsh CL, Ibrahim K, Sukhodolsky DG. Assessing Irritability in Children with Autism Spectrum Disorder Using the Affective Reactivity Index. J Autism Dev Disord. 2021 May;51(5):1496-1507. doi: 10.1007/s10803-020-04627-9.