Irritability in child and adolescent anxiety disorders

Family Accommodation in Anxious Irritable and Anxious Nonirritable Youth

Family accommodation is a significant contributor to the maintenance and course of youth anxiety. There is also high co-occurrence of anxiety and irritability in youth. Research is lacking, however, on the influence of irritability in the association between anxiety and family accommodation, including among youth with clinically diagnosed anxiety disorders. We therefore examined this issue in a sample of clinic-referred anxious irritable and anxious nonirritable youth. Youth (N = 645, Mage = 9.86 years, SD = 2.92) and their parents completed diagnostic interviews and questionnaires assessing youth anxiety, irritability, and family accommodation. Based on both youth and parent ratings, family accommodation was significantly and positively associated with youth anxiety and irritability. Anxious irritable youth rated family accommodation significantly higher than anxious nonirritable youth. In addition, youth self-rated irritability levels significantly moderated the association between their anxiety and family accommodation. No moderation effect was found for the parent ratings. Based on the youth ratings, our overall findings show that parents of anxious irritable youth are more accommodating of their children's anxiety, compared with parents of anxious nonirritable youth. Anxiety levels also predict family accommodation more strongly in youth with lower levels of irritability. Our findings provide novel insights about accommodation behaviors in families of anxious irritable youth and suggest its potential utility as a treatment target when working with anxious irritable youth.

Sleepless nights, sour moods: daily sleep-irritability links in a pediatric clinical sample

BACKGROUND

Sleep, or a lack thereof, is strongly related to mood dysregulation. Although considerable research uses symptom scales to examine this relation, few studies use longitudinal, real-time methods focused on pediatric irritability. This study leveraged an ecological momentary assessment (EMA) protocol, assessing bidirectional associations between momentary irritability symptoms and daily sleep duration in a transdiagnostic pediatric sample enriched for irritability.

METHODS

A total of N = 125 youth (Mage = 12.58 years, SD = 2.56 years; 74% male; 68.8% White) completed digital, in vivo surveys three times a day for 7 days. For a subset of youth, their parents also completed the EMA protocol. Trait irritability was measured using youth-, parent-, and clinician-report to test its potential moderating effect on the association between sleep duration and momentary irritability.

RESULTS

Results from multilevel modeling dynamically linked sleep to irritability. Specifically, according to youth- and parent-report, decreased sleep duration was associated with increased morning irritability (bs ≤ -.09, ps < .049). A bidirectional association between parent-reported nightly sleep duration and anger was found-increased evening anger related to decreased nightly sleep duration, and decreased sleep duration related to increased morning anger (bs ≤ -.17, ps < .019). Trait irritability moderated this association, which was stronger for more irritable youth (b = -.03, p < .027).

CONCLUSIONS

This study adds to the literature and suggests sleep-irritability dynamics as a potential treatment target.

Psychometric Evaluation of the Affective Reactivity Index Among Children and Adolescents in China: A Multi-Method Assessment Approach

The Affective Reactivity Index (ARI) is one of the most studied scales for assessing youth irritability, but little is known about its measurement performance in community populations. This study applied item response theory (IRT), network analysis, and classical test theory (CTT) to examine the psychometric properties of the ARI in a sample of n = 395 community-based children (Mage = 13.44, SD = 2.51) and n = 403 parents. In this sample, the ARI demonstrated good reliability, as well as convergent and concurrent validity. The one-factor structure was supported by both confirmatory factor analysis (CFA) and network analysis. IRT analysis revealed that the ARI effectively distinguished between various levels of irritability within the community population. Network analysis identified "Loses temper easily,""Gets angry frequently," and "Often loses temper" are central aspects of irritability. The findings support the ARI as a brief, reliable, and valid instrument to assess irritability in community children and adolescents.

Irritability in young people with copy number variants associated with neurodevelopmental disorders (ND-CNVs)

A range of rare mutations involving micro-deletion or -duplication of genetic material (copy number variants (CNVs)) have been associated with high neurodevelopmental and psychiatric risk (ND-CNVs). Irritability is frequently observed in childhood neurodevelopmental conditions, yet its aetiology is largely unknown. Genetic variation may play a role, but there is a sparsity of studies investigating the presentation of irritability in young people with ND-CNVs. This study aimed to investigate whether there is a difference in irritability in young people with rare ND-CNVs compared to those without ND-CNVs, and to what extent irritability is associated with psychiatric diagnoses and cognitive ability (IQ). Irritability and broader psychopathology were assessed in 485 young people with ND-CNVs and 164 sibling controls, using the child and adolescent psychiatric assessment. Autism was assessed using the social communication questionnaire, and intelligence quotient (IQ) by the Wechsler abbreviated scale of intelligence. Fifty four percent of young people with ND-CNVs met the threshold for irritability; significantly more than controls (OR = 3.77, CI = 3.07-7.90, p = 5.31 × 10-11). When controlling for the presence of other psychiatric comorbidities, ND-CNV status was still associated with irritability. There was no evidence for a relationship between irritability and IQ. Irritability is an important aspect of the clinical picture in young people with ND-CNVs. This work shows that genetic variation is associated with irritability in young people with ND-CNVs, independent of psychiatric comorbidities or IQ impairment. Clinicians should be aware of this increased risk to inform management and interventions.

Phasic Versus Tonic Irritability and Associations with Family Accommodation Among Youth with Selective Mutism: A Latent Profile Analysis

Clinical presentations of selective mutism (SM) vary widely across affected youth. Although studies have explored general externalizing problems in youth with SM, research has not specifically examined patterns of irritability. Relatedly, research has not considered how affected families differentially accommodate the anxiety of youth with SM as a function of the child's temper outbursts (i.e., phasic irritability) and general angry mood (i.e., tonic irritability). Data were drawn from a sample of treatment-seeking children and adolescents with a primary diagnosis of selective mutism (N = 152; Mean age = 6.12 years; 67.11% female), and their caregivers. Latent profile analysis (LPA) was used to identify distinct profiles in SM youth that were characterized by varying levels of phasic and/or tonic irritability. Analyses further examined whether these different profiles were associated with different levels of family accommodation and global impairment. LPA identified 5 profiles: SM with No irritability, SM with Low Phasic Irritability, SM with High Phasic Irritability, SM with High Phasic and Moderate Tonic Irritability, and SM with High Phasic and High Tonic Irritability. Patterns of family accommodation and global impairment were highest among youth belonging to profiles characterized by high phasic irritability. Findings highlight separable patterns of irritability across youth with SM, with phasic irritability (i.e., temper outbursts) appearing particularly linked with increased family accommodation and overall global impairment. Assessing phasic irritability is critical for optimizing treatment in youth with SM and can be useful for flagging possible patterns of family accommodation contributing to overall impairment.

Weekly links among irritability and suicidal thoughts and behaviors in high-risk youth

BACKGROUND

Previous studies demonstrate a link between irritability and suicidal thoughts and behaviors (STBs) in youth samples. However, they have mostly assessed irritability in community samples and as a largely dispositional (i.e. trait-like) construct. Thus, it remains unclear to what extent links between irritability and STBs reflect within-person processes of elevated risk in clinically meaningful time periods.

METHODS

The present study used clinical data from 689 adolescents aged 12-19 years attending a total of 6,128 visits at a specialty Intensive Outpatient Program for depressed and suicidal youth to examine patterns in weekly assessments of irritability and STBs throughout treatment, including associations among trends and fluctuations departing from these trends via multilevel structural equation modeling. Youth completed self-report measures of irritability, depression, and STBs weekly as part of standard IOP clinical care.

RESULTS

Overall, two-thirds of variance in weekly irritable mood was accounted for by between-person differences and the remaining portion by weekly fluctuations. After controlling for depression, during weeks when youth were more irritable they experienced increased STBs. Rates of change in irritability and STBs tended to track together at early stages of treatment, but these effects were generally accounted for by depression severity.

CONCLUSIONS

Our results suggest that although changes in STBs are best accounted for by depression, irritability can be understood as a specific, proximal risk factor for youth STBs that exacerbates youth STBs in clinically informative timeframes above and beyond depression.

Social anxiety moderates the association between adolescent irritability and bully perpetration

BACKGROUND

Preliminary work suggests anxiety moderates the relationship between irritability and bullying. As anxiety increases, the link between irritability and perpetration decreases. We hypothesize that any moderation effect of anxiety is driven by social anxiety symptoms. We sought to explicate the moderating effect of anxiety, while clarifying relations to other aggressive behaviors.

METHODS

A sample of adolescents (n = 169, mean = 12.42 years of age) were assessed using clinician rated assessments of anxiety, parent reports of irritability and bullying behaviors (perpetration, generalized aggression, and victimization). Correlations assessed zero-order relations between variables, and regression-based moderation analyses were used to test interactions. Johnson-Neyman methods were used to represent significant interactions.

RESULTS

Irritability was significantly related to bullying (r = .403, p < .001). Social, but not generalized, anxiety symptoms significantly moderated the effect of irritability on bully perpetration (t(160) = -2.94, b = -.01, p = .0038, ΔR2 = .0229, F(1, 160) = 8.635). As social anxiety symptoms increase, the link between irritability and perpetration decreases.

CONCLUSIONS

Understanding how psychopathology interacts with social behaviors is of great importance. Higher social anxiety is linked to reduced relations between irritability and bullying; however, the link between irritability and other aggression remains positive. Comprehensively assessing how treatment of psychopathology impacts social behaviors may improve future intervention.

An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

OBJECTIVE

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

METHOD

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

RESULTS

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

CONCLUSIONS

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

Frustration Response and Regulation Among Irritable Children: Contributions of Chronic Irritability, Internalizing, and Externalizing Symptoms

OBJECTIVE

The need to understand and treat childhood chronic irritability (CI; i.e. frequent temper loss and angry/irritable mood) is imperative. CI predicts impairment across development and complex comorbidities with both internalizing and externalizing disorders. Research has emphasized frustration reactivity as a key mechanism of CI. However, there are understudied components of frustrative non-reward, particularly regulation-oriented frustration recovery, frustration tolerance, and cognitive control, that may further explain impairments specific to CI beyond comorbid symptoms.

METHOD

Sixty-three community children (N = 25 CI/38 non-CI) and a parent completed surveys and the computerized Frustration Go/No-Go (FGNG) and Mirror Tracing Persistence Task (MTPT). Analyses compared task performance and self-rated affect across youth with or without CI, with further comparison based on negative/positive screen for ADHD (N = 45-/18+).

RESULTS

In mixed effects models assessing change across task, the CI group did not demonstrate more intense frustration on the MTPT or rigged FGNG block but exhibited persisting frustration and inhibitory control difficulties into the FGNG recovery period; the CI+ADHD subgroup drove recovery effects. In GEE and logistic regression models including dimensional symptom clusters, only internalizing symptoms predicted child frustration intolerance and reactivity across tasks. ADHD severity was also associated with higher MTPT frustration reactivity, while oppositional behavior predicted lower frustration. Better frustration recovery was associated with lower irritability, but higher internalizing symptoms.

CONCLUSIONS

Co-occurring symptoms may better explain some frustration-related difficulties among youth with CI. Difficulties with postfrustration affect and inhibitory control recovery suggest the importance of characterizing CI by self-regulation impairments.

Novel Assessment of the Impact of Irritability on Physiological and Psychological Frustration Responses in Adolescents

OBJECTIVE

Irritability, typically defined as a proneness to anger, particularly in response to frustration, falls at the intersection of emotion and disruptive behavior. Despite well-defined translational models, there are few convergent findings regarding the pathophysiology of irritability. Most studies utilize computer-based tasks to examine neural responses to frustration, with little work examining stress-related responding to frustration in social contexts. The present study is the first to utilize the novel Frustration Social Stressor for Adolescents (FSS-A) to examine associations between adolescent irritability and psychological and physiological responses to frustration.

METHOD

The FSS-A was completed by a predominantly male, racially, ethnically, and socioeconomically diverse sample of 64 12- to 17-year-olds, who were originally recruited as children with varying levels of irritability. Current irritability was assessed using the Multidimensional Assessment Profiles-Temper Loss scale (MAP-TL-Youth). Adolescents rated state anger and anxiety before and after the FSS-A, and usable salivary cortisol data were collected from 43 participants.

RESULTS

Higher MAP-TL-Youth scores were associated with greater increases in anger during the FSS-A, but not increases in anxiety, or alterations in cortisol. Pre-task state anger negatively predicted the slope of the rise in cortisol observed in anticipation of the FSS-A.

CONCLUSIONS

Results provide support for unique associations between adolescent irritability and anger during, and in anticipation of, frustrating social interactions. Such findings lay a foundation for future work aimed at informing physiological models and intervention targets.

Irritability, Negative Life Events and the Course of Anxiety and Depressive Symptoms in a Clinical Sample of Youth: A Longitudinal Study

Objective

Irritability, the tendency to react with anger, and the experience of negative life events (NLE) have independently been associated with the emergence of anxiety and depression. Here, we investigate how irritability and cumulative effects of NLE interactively predict the course of anxiety and depression in the context of common psychiatric disorders.

Method

432 youth with no psychiatric diagnosis, or a diagnosis of an anxiety disorder, Attention-Deficit/ Hyperactivity Disorder (ADHD), or Disruptive Mood Dysregulation Disorder (DMDD), participated in this study. At baseline, we assessed NLE, parent and youth reports of irritability and anxiety, and youth reports of depression. Symptoms were annually reassessed for up to four years.

Results

In youth without psychiatric diagnoses but with elevated baseline irritability, the presence of NLE predicted decreasing anxiety, while the absence of NLE predicted increasing anxiety. In youth with an anxiety disorder, elevated baseline irritability predicted decreasing anxiety independent of NLE, while a large cumulative effect of NLE predicted increasing depression. NLE predicted persisting mild anxiety in ADHD and persisting mild depressive symptoms in DMDD.

Conclusion

Our findings suggest that, particularly in non-referred samples, NLE might moderate the relationship between irritability and future anxiety such that irritability/ anger in the context of NLE can positively affect the course of anxiety. Future work replicating this finding while repeatedly measuring NLE and rigorously controlling for potentially confounding effects of treatment, is warranted.

What I see, what you say: How cross-method variation sharpens characterization of irritability in early childhood

OBJECTIVES

Identification of clinically significant irritability in preschool age is important to implement effective interventions. However, varying informant and measurement methods display distinct patterns. These patterns are associated with concurrent and future mental health concerns. Patterns across multi-informant methods in early-childhood irritability may have clinical utility, identifying risk for impaired psychosocial functioning.

METHODS

Using data from the Multidimensional Assessment of Preschoolers Study (N = 425), latent profile analysis identified irritability patterns through the parent-reported Multidimensional Assessment Profile Scales-Temper Loss (MAPS-TL), parent-reported interviewer-rated Preschool Age Psychiatric Assessment (PAPA), and observer-rated Disruptive Behavior Diagnostic Observation Schedule (DB-DOS). These profiles were characterized on protective factors, global functioning, and mental health syndromes, concurrently and at early school age and preadolescent follow-up.

RESULTS

Fit indices favored a five-class model: Low All, High Observation with Examiner (high DB-DOS Examiner Context), High All, High Parent Report (high MAPS-TL/PAPA), and Very High Parent Report (very high MAPS-TL/PAPA). Whereas Low All and High Observation with Examiner exhibited strong psychosocial functioning, remaining profiles showed impaired psychosocial functioning, with the Very High Parent Report group showing higher impairment at follow-ups, ds = 0.37-1.25.

CONCLUSIONS

Multi-informant measurements of irritability may have utility for clinical prediction, and future studies should test utility for diagnostic precision.

Association Between Child Maltreatment and Aggression in Chinese Early Adolescents: The Mediating Role of Irritability

Child maltreatment (CM) is a major global public health issue, and a strong association exists between CM and aggression. However, the underlying mechanism of this association has not been understood to date. The objective of this study was to explore the mediating role of irritability in the association between CM and aggression in Chinese early adolescents. A cross-sectional study was conducted using a self-report questionnaire to evaluate the levels of CM, aggression, and irritability in 5,724 middle school students from the Anhui Province, China. Structural equation modeling was used to test the hypothesis of the mediating effect of irritability on the relationship between CM and aggression. We further investigated gender differences in this association using multiple group analyses. CM was positively related to both irritability and aggression, and irritability was positively associated with aggression (p < .01). The mediating effects of irritability between CM and aggression were significant (β = .107, 95% confidence intervals [CI]: 0.077-0.133, p < .05). Males had a higher indirect effect size of the pathway from CM to aggression via irritability compared with females. Overall, irritability was a crucial mediator in the relationship between CM and aggression in Chinese adolescents, and males were more prone to engage in aggression compared with females through the pathway of irritability. Therefore, early irritability characteristics should be carefully monitored in adolescents, and they should be provided adequate support to acquire critical emotion regulation skills.

Irritability in young people with copy number variants associated with neurodevelopmental disorders (ND-CNVs)

Background

A range of rare mutations involving micro-deletion or -duplication of genetic material (copy number variants (CNVs)) have been associated with high neurodevelopmental and psychiatric risk (ND-CNVs). Irritability is frequently observed in childhood neurodevelopmental conditions, yet its aetiology is largely unknown. Genetic variation may play a role, but there is a sparsity of studies investigating presentation of irritability in young people with ND-CNVs.

Aims

This study aimed to investigate whether there is a difference in irritability in young people with rare ND-CNVs compared to those without ND-CNVs, and to what extent irritability is associated with psychiatric diagnoses and cognitive ability (IQ).

Methods

Irritability and broader psychopathology was assessed in 485 young people with ND-CNVs and 164 sibling controls, using the child and adolescent psychiatric assessment (CAPA). Autism was assessed using the Social Communication Questionnaire (SCQ), and Intelligence Quotient (IQ) by the Wechsler Abbreviated Scale of Intelligence (WASI).

Results

54% of young people with ND-CNVs met the threshold for irritability; significantly more than controls (OR = 3.77, CI = 3.07-7.90, p= 5.31 × 10-11). When controlling for the presence of other psychiatric comorbidities, ND-CNV status was still associated with irritability. There was no evidence for a relationship between irritability and IQ.

Conclusions

Irritability is an important aspect of the clinical picture in young people with ND-CNVs. This work shows that genetic variation is associated with irritability in young people with ND-CNVs, independent of psychiatric comorbidities or IQ impairment. Clinicians should be aware of this increased risk to inform management and interventions.

Transactional associations of child irritability and anxiety with parent psychological control in Taiwanese school-aged children

Background

Child irritability and anxiety are associated with parent psychological control; yet their transactional relations over time are not well-characterized at the within-person level. Research addressing generalizability of past Western-based literature in non-Western, collectivist community samples is lacking.

Methods

Sample comprised 285 children aged 8.8-11.4 years (145 girls; Mage = 9.9 years, SD = 0.6) in Northern Taiwan. Participants were assessed at baseline (T1), 6-month (T2), and 12-month (T3) follow-ups. Child irritability and anxiety symptoms were assessed using parent-rated Child Behavior Checklist. Parent psychological control was assessed using the parent- and child-rated Psychological Control Scale. Within-person processes were specified using the random-intercept cross-lagged panel models.

Results

Models showed that psychological control predicted increased child irritability when analyzing parenting data from parents and children. However, the lagged effect from psychological control to child anxiety was only seen in parent-rated parenting data. We found limited evidence for a back-and-forth transactional pathway among constructs. Child irritability predicted increased child anxiety in all models.

Conclusions

Directional effects from psychological control to child irritability and anxiety support parent-involved interventions that prioritize collaborative parenting and positive reinforcement techniques. Future validations in combined clinical and typically developing samples and direct cross-cultural comparisons are warranted.

A cross-sectional analysis of the relationships between anxiety sensitivity and youth irritability: the mediated roles of insomnia and selective attention for threat

BACKGROUND

Irritability is common in multiple psychiatric disorders and is hallmark of disruptive mood dysregulation disorder. Child irritability is associated with higher risk of suicide and adulthood mental health problems. However, the psychological mechanisms of irritability are understudied. This study examined the relationship between anxiety sensitivity and irritability among youth, and further explored three possible mediated factors: selective attention for threat, delayed reward discounting, and insomnia.

METHODS

Participants were 1417 students (51.7% male; mean age 13.83 years, SD = 1.48) recruited from one high school in Hunan province, China. Self-report questionnaires were used to measure irritability (The Affective Reactivity Index and The Brief Irritability Test), anxiety sensitivity (The Childhood Anxiety Sensitivity Index), selective attention for threat (The Davos Assessment of Cognitive Biases Scale-attention for threat bias subscale), insomnia (The Youth Self-Rating Insomnia Scale), and delayed reward discounting (The 27-item Monetary Choice Questionnaire). Structural equation modal (SEM) was performed to examine mediated relations.

RESULTS

Anxiety sensitivity was modestly related to irritability and insomnia (r from 0.25 to 0.54) and slightly correlated with selective attention for threat (r from 0.12 to 0.28). However, there is no significant relationship of delayed rewards discounting with anxiety sensitivity and irritability. The results of SEM showed that selective attention for threat (indirect effect estimate = 0.04) and insomnia (indirect effect estimate = 0.20) partially mediate the relationship between anxiety sensitivity and irritability, which explained 34% variation.

CONCLUSIONS

Anxiety sensitivity is an important susceptibility factor for irritability. Selective attention for threat and insomnia are two mediated mechanisms to understand the relationship between anxiety sensitivity and irritability.

Associations between childhood irritability and neural reactivity to maternal feedback in adolescence

Early irritability, a transdiagnostic vulnerability for psychopathology, is associated with alterations in neural reactivity to emotional stimuli and reward; however, associations between childhood irritability and neural markers of risk may be mitigated by the quality of caregiving youth receive. We examined longitudinal relationships between irritability in childhood and young adolescents' neural activity of regions typically associated with emotion regulation and reward processing during processing of maternal feedback and tested whether these associations were moderated by youth's perceptions of the parent-child relationship quality. Eighty-one adolescents (Mage = 11.1 years) listened to maternal critical and praising feedback while undergoing functional magnetic resonance imaging. Age 3 irritability, assessed observationally, was negatively associated with age 11 neural reactivity to maternal criticism in a cluster in the right dorsolateral prefrontal cortex (dlPFC), particularly for youths who reported more positive maternal parenting. Given the role of the dlPFC activation in the effortful processing of emotional stimuli, decreased activation may reflect disengagement from negatively valenced interpersonal feedback in the context of a positive caregiving environment, thereby mitigating psychopathology risk associated with irritability.

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child's anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children's anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.

Parenting and childhood irritability: Negative emotion socialization and parental control moderate the development of irritability

Irritability, characterized by anger in response to frustration, is normative in childhood. While children typically show a decline in irritability from toddlerhood to school age, elevated irritability throughout childhood may predict later psychopathology. The current study (n = 78) examined associations between trajectories of irritability in early childhood (ages 2-7) and irritability in adolescence (age 12) and tested whether these associations are moderated by parenting behaviors. Results indicate that negative emotion socialization moderated trajectories of irritability - relative to children with low stable irritability, children who exhibited high stable irritability in early childhood and who had parents that exhibited greater negative emotion socialization behaviors had higher irritability in adolescence. Further, negative parental control behavior moderated trajectories of irritability - relative to children with low stable irritability, children who had high decreasing irritability in early childhood and who had parents who exhibited greater negative control behaviors had higher irritability in adolescence. In contrast, positive emotion socialization and control behaviors did not moderate the relations between early childhood irritability and later irritability in adolescence. These results suggest that both irritability in early childhood and negative parenting behaviors may jointly influence irritability in adolescence. The current study underscores the significance of negative parenting behaviors and could inform treatment.

Robust caregiver-youth discrepancies in irritability ratings on the affective reactivity index: An investigation of its origins

OBJECTIVE

The Affective Reactivity Index (ARI) is widely used to assess young people's irritability symptoms, but youth and caregivers often diverge in their assessments. Such informant discrepancy might be rooted in poor psychometric properties, the differential conceptualization of irritability across informants, or reflect sociodemographic and clinical characteristics. We use an out-of-sample replication approach and leverage longitudinal data, available for a subset of the participants, to test these hypotheses.

METHOD

Across two independent samples (NCohort-1 = 765, 8-21 years; NCohort-2 = 1910, 6-21 years), we investigate the reliability and measurement invariance of the ARI, examine sociodemographic and clinical predictors of discrepant reporting and probe the utility of a bifactor model for cross-informant integration.

RESULTS

Despite good internal consistency and 6-week-retest-reliability of parent (Cohort-1: α = 0.92, ICC = 0.85; Cohort-2: α = 0.93) and youth forms (Cohort-1: α = 0.88, ICC = 0.78; Cohort-2: α = 0.82), we confirm substantial informant discrepancy in ARI ratings (3 points on a scale from 0 to 12), which is stable over six weeks (ICC = 0.53). Measurement invariance across informants was weak, indicating that parents and youth may interpret ARI items differently. Irritability severity and diagnostic status predicted informant-discrepancy, albeit in opposing directions: higher severity was linked to relative, higher irritability-ratings by youth (Cohort-1: β = -0.06, p < .001; Cohort-2: β = -0.06, p < .001), while diagnoses of Disruptive Mood Dysregulation Disorder (Cohort-1: β = 0.44, p < .001; Cohort-2: β = 0.84, p < .001) and Oppositional Defiant Disorder (Cohort-1: β = 0.41, p < .001; Cohort-2: β = 0.42, p < .001) predicted relative higher irritability-ratings by caregivers. In both datasets, a bifactor model parsing informant-specific from shared irritability-related variance fit the data well (CFI = 0.99, RMSEA = 0.05; N2: CFI = 0.99; RMSEA = 0.04).

CONCLUSION

Parent and youth ARI reports and their discrepancy are reliable and reflect different interpretations of the scale items; hence they should not be averaged. This finding also suggests that irritability is not a unitary construct. Future work should investigate and model how different aspects of irritability might differ in their impact on the responses of specific informants.

Neural correlates of peer evaluation in irritable adolescents: Linking anticipation to receipt of social feedback

Elevated irritability during adolescence predicts mental health issues in adulthood. Social interactions commonly elicit symptoms of irritability. Prior research has traditionally examined neural activity during the anticipation of, and immediate reaction to, social feedback separately in irritable adolescents. However, studies suggest that irritable adolescents demonstrate altered brain activation when anticipating feedback, and these alterations may have downstream effects on the neural activity when actually presented with feedback. Thus, the goal of this study was to characterize the influence of irritability on the relationship between brain function during anticipation and receipt of social feedback. We leveraged the Virtual School task to mimic social interactions using dynamic stimuli. Parallel region of interest (ROI) analyses tested effects of anticipatory bilateral amygdala (or dorsal anterior cingulate cortex; dACC) activation on the dACC (or bilateral amygdala) activation during receipt of peer feedback. Parallel exploratory whole-brain analyses were conducted to identify the effects of anticipatory bilateral amygdala or dACC activation on other regions during receipt of peer feedback. In ROI analyses, more vs. less irritable adolescents showed distinct relationships between anticipatory bilateral amygdala activation and dACC activation when receiving predictably mean feedback. Across both whole-brain analyses, anticipatory bilateral amygdala and dACC activation were separately associated with activation in socioemotional regions of the brain during subsequent feedback. These relationships were modulated by irritability, and the valence and predictability of the feedback. This suggests that irritable adolescents may engage in altered emotion processing and regulation strategies, depending on the valence and predictability of social feedback.

Context-dependent amygdala-prefrontal connectivity during the dot-probe task varies by irritability and attention bias to angry faces

Irritability, defined as proneness to anger, is among the most common reasons youth are seen for psychiatric care. Youth with irritability demonstrate aberrant processing of anger-related stimuli; however, the neural mechanisms remain unknown. We applied a drift-diffusion model (DDM), a computational tool, to derive a latent behavioral metric of attentional bias to angry faces in youth with varying levels of irritability during functional magnetic resonance imaging (fMRI). We examined associations among irritability, task behavior using a DDM-based index for preferential allocation of attention to angry faces (i.e., extra-decisional time bias; Δt₀), and amygdala context-dependent connectivity during the dot-probe task. Our transdiagnostic sample, enriched for irritability, included 351 youth (ages 8-18; M = 12.92 years, 51% male, with primary diagnoses of either attention deficit/hyperactivity disorder [ADHD], disruptive mood dysregulation disorder [DMDD], an anxiety disorder, or healthy controls). Models accounted for age, sex, in-scanner motion, and co-occurring symptoms of anxiety. Youth and parents rated youth's irritability using the Affective Reactivity Index. An fMRI dot-probe task was used to assess attention orienting to angry faces. In the angry-incongruent vs. angry-congruent contrast, amygdala connectivity with the bilateral inferior frontal gyrus (IFG), insula, caudate, and thalamus/pulvinar was modulated by irritability level and attention bias to angry faces, Δt₀, all ts₃₅₀ > 4.46, ps < 0.001. In youth with high irritability, elevated Δt₀ was associated with a weaker amygdala connectivity. In contrast, in youth with low irritability, elevated Δt₀ was associated with stronger connectivity in those regions. No main effect emerged for irritability. As irritability is associated with reactive aggression, these results suggest a potential neural regulatory deficit in irritable youth who have elevated attention bias to angry cues.

The Feasibility, Acceptability, and Efficacy of Positive Search Training for Irritable Youth: A Single-Case Experimental Design

Although irritability is common in youth, research on treatment is in its infancy. Threat biases are more pronounced in irritable compared to low irritable youth, similar to evidence found in anxious youth. Therefore, interventions targeting these biases may be promising for reducing irritability. This study utilised a multiple baseline case series design to determine the feasibility, acceptability, and efficacy of positive search training (PST) for irritable children. Three children were included who met criteria for a principal diagnosis of Disruptive Mood Dysregulation Disorder (DMDD), and a secondary diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) or Major Depressive Disorder (MDD). PST was feasible with two of the three participants; one child refused to continue after one session. For the two participants who completed PST, acceptability was stable with moderate-to-high ratings of engagement and enjoyment, and high and stable treatment-relevant verbalisations of the key strategies. Both cases showed declines in DMDD severity across treatment and no longer met criteria at post-treatment. Both participants met criteria for Oppositional Defiant Disorder (ODD) at post-treatment (considered less severe for irritability than DMDD). Declines in parent-reported irritability occurred for both cases, however some returns to baseline were observed. Overall, PST for irritable youth shows promise as an acceptable and feasible intervention. Further studies are needed combining PST with strategies for secondary diagnoses, given its high comorbidity with disruptive behaviour disorders.

Childhood Irritability: Predictive Validity and Mediators of Adolescent Psychopathology

Despite its transdiagnostic significance, there is modest evidence with respect to the predictive validity of childhood irritability, especially across developmental periods; similarly, little is known about explanatory factors underlying these predictions. This study had two goals: (1) to test the predictive validity of childhood irritability with respect to adolescent internalizing and externalizing problems, controlling for baseline ADHD and related psychopathology and (2) to test theoretically-derived family (i.e., parenting behavior, parenting stress) and social (i.e., peer status, social skills) constructs as explanatory factors of adolescent psychopathology. Two hundred thirty ethnically diverse (51.5% White) 5-10-year-old youth (32% female) with (n = 121) and without (n = 110) ADHD completed three separate laboratory-based assessments across six to seven years. Temporally-ordered predictors, putative mediators, and psychopathology outcomes were assessed using multiple informants (i.e., parent, teacher, youth) and methods (i.e., structured interviews, normed rating scales). Controlling for demographic factors, clinical correlates, and baseline psychopathology, childhood irritability uniquely predicted adolescent externalizing problems, but not internalizing problems. Next, analyses revealed that low social skills partially explained predictions of adolescent internalizing problems. However, family or social factors did not underlie predictions of adolescent externalizing problems. These preliminary findings support the predictive validity of childhood irritability with respect to early adolescent externalizing problems and implicate low social skills as a potentially unique mediator of internalizing outcomes. Intervention-induced improvements in social skills may minimize emergent psychopathology initiated by significant childhood irritability.

Understanding Irritability in Relation to Anger, Aggression, and Informant in a Pediatric Clinical Population

OBJECTIVE

Despite its clinical relevance to pediatric mental health, the relationship of irritability with anger and aggression remains unclear. We aimed to quantify the relationships between well-validated, commonly used measurements of these constructs and informant effects in a clinically relevant population.

METHOD

A total of 195 children with primary diagnoses of attention-deficit/hyperactivity disorder, disruptive mood dysregulation disorder, or no major disorder and their parents rate irritability, anger, and aggression on measures of each construct. Construct and informant relationships were mapped via multi-trait, multi-method factor analysis.

RESULTS

Parent- and child-reported irritability and child-reported anger are highly associated (r = 0.89) but have some significant differences. Irritability overlaps with outward expression of anger but diverges from anger in anger suppression and control. Aggression has weaker associations with both irritability (r = 0.56) and anger (r = 0.49). Across measures, informant source explains a substantial portion of response variance.

CONCLUSION

Irritability, albeit distinct from aggression, is highly associated with anger, with notable overlap in child-reported outward expression of anger, providing empirical support for formulations of clinical irritability as a proneness to express anger outwardly. Diagnostic and clinical intervention work on this facet of anger can likely translate to irritability. Further research on external validation of divergence of these constructs in anger suppression and control may guide future scale revisions. The proportion of response variance attributable to informant may be an under-recognized confound in clinical research and construct measurement.

Preschool Irritability Predicts Adolescent Psychopathology and Functional Impairment: A 12-Year Prospective Study

OBJECTIVE

The long-term clinical and functional outcomes of preschool-age irritability are unknown. This study examined longitudinal associations of preschool irritability with psychiatric disorders and functional impairment assessed in adolescence in a large community sample.

METHOD

A total of 453 children were assessed at age 3 and again at ages 12 and/or 15. At age 3, parents were interviewed about their child's irritability, other psychiatric symptoms, and functional impairment with the Preschool Age Psychiatric Assessment (PAPA). In adolescence, both parents and youths were interviewed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) to assess youth psychopathology and functional impairment; youths also completed the UCLA Life Stress Interview (LSI) to assess different domains of functioning. Lastly, youths and parents completed the Children's Depression Inventory 2 (CDI 2) and the Screen for Child Anxiety Related Disorders (SCARED).

RESULTS

Irritability at age 3 predicted internalizing and externalizing disorders in adolescence; parent-reported anxiety and depressive symptoms; and greater functional impairment, including poorer peer functioning, poorer physical health, and antidepressant and educational service use, even after controlling for baseline psychiatric disorders. All longitudinal associations persisted after further adjusting for well-established early life risk markers for psychopathology.

CONCLUSION

The findings of this study underscore the clinical significance and predictive power of preschool irritability and provide support for its use in large-scale identification and intervention efforts.

Underlying mechanisms of disruptive mood dysregulation disorder in children: A systematic review by means of research domain criteria

Background

A systematic overview of underlying mechanisms in the new disruptive mood dysregulation disorder (DMDD) diagnosis is needed. The Research Domain Criteria (RDoC) represent a system of six domains of human functioning, which aims to structure the understanding of the nature of mental illnesses. By means of the RDoC framework, the objective of this systematic review is to synthesize available data on children and youths <18 years suffering from DMDD as reported in peer reviewed papers.

Methods

A literature search guided by PRISMA was conducted using Medline, PsychInfo, and Embase, while the RDoC domains were employed to systematize research findings. Risk of bias in the included studies was examined.

Results

We identified 319 studies. After study selection, we included 29 studies. Twenty-one of these had findings relating to >1 RDoC domain. The risk of bias assessment shows limitations in the research foundation of current knowledge on mechanisms of DMDD.

Discussion

Reviewing self-report, behavior and neurocircuit findings by means of RDoC domains, we suggest that DMDD youths have a negative interpretation bias in social processes and valence systems. In occurrence of a negative stimuli interpretation, aberrant cognitive processing may arise. However, current knowledge of DMDD is influenced by lack of sample diversity and open science practices.

Conclusion

We found the six RDoC domains useful in structuring current evidence of the underlying mechanisms of DMDD. Important opportunities for future studies in this field of research are suggested. In clinical practice, this comprehensive summary on DMDD mechanisms can be used in psychoeducation and treatment plans.

Does irritability predict attention biases toward threat among clinically anxious youth?

Aberrant threat processing is a known cognitive characteristic of anxiety disorders and irritability. Youth with more severe symptomatology show greater allocation of attention towards threat relative to neutral stimuli. Although irritability contributes to poorer outcomes among anxious youths, irritability has not been considered as a contributing factor to threat processing in anxiety disorders. Thus, the current study examined the role of irritability in predicting attention biases for threat among clinically anxious youth. Our study included 84 clinically anxious youth (M = 9.31 years old, SD = 2.44) who completed a dot-probe task to determine attention biases. Anxiety disorders were assessed using semi-structured diagnostic interviews. Well validated measures were used to assess the severity of anxiety and irritability symptoms via child- and parent-report, respectively. Findings indicated that more severe irritability predicted greater attention biases toward threat among clinically anxious youth, covarying for age, anxiety severity, and the number of comorbid diagnoses. At a trend-level, anxiety severity also predicted attention bias for threat. Among clinically anxious youth, irritability severity was the strongest predictor of attention bias toward threat. Findings point to the salience of irritability, and to some extent anxiety severity, in relation to threat processing among youth with clinical anxiety disorders.

Associations Between Chronic Irritability and Sensory Processing Difficulties in Children and Adolescents

Irritability is one of the most common reasons for which children and adolescents are referred for psychiatric evaluation and care. However, clinical irritability is difficult to define; thus, its prevalence varies widely. Chronic irritability may be associated with sensory processing difficulties (SPD), but little is known about the relationship between these two factors in clinical populations. In this study, we examined the prevalence of chronic irritability and its association with SPD in 166 children aged 5-16 years who were referred to the psychiatric outpatient clinic of the Osaka City University Hospital. Chronic irritability and parent-reported scores for the Short Sensory Profile, Infant Behavior Checklist-Revised, Child Behavior Checklist, and Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (Present and Lifetime version) questionnaires were used for assessment. A total of 22 children (13.2%) presented with chronic irritability (i.e., the irritability group) and were more likely to have oppositional defiant disorder, externalizing problems, and attention issues than those without chronic irritability (i.e., the control group). SPD were reported in eight (36%) patients in the irritability group and in 21 (15%) in the control group (p = 0.029). Moreover, compared to the control group, the irritability group showed a significant difference in almost all items of the Short Sensory Profile. Chronic irritability was associated with more severe overall SPD, even after adjusting for possible confounding factors (internalizing and externalizing problems, age, sex, and low income). We provide evidence to support our hypothesis that chronic irritability is associated with SPD in children and adolescents. Therefore, SPD should be assessed to provide appropriate interventions in children and adolescents with chronic irritability.

Anxiety, Anger and Depression Amongst Low-Income Earners in Southwestern Uganda During the COVID-19 Total Lockdown

Background: Low-income earners are particularly vulnerable to mental health, consequence of the coronavirus disease 2019 (COVID-19) lockdown restrictions, due to a temporary or permanent loss of income and livelihood, coupled with government-enforced measures of social distancing. This study evaluates the mental health status among low-income earners in southwestern Uganda during the first total COVID-19 lockdown in Uganda. Methods: A cross-sectional descriptive study was undertaken amongst earners whose income falls below the poverty threshold. Two hundred and fifty-three (n = 253) male and female low-income earners between the ages of 18 and 60 years of age were recruited to the study. Modified generalized anxiety disorder (GAD-7), Spielberger's State-Trait Anger Expression Inventory-2 (STAXI-2), and Beck Depression Inventory (BDI) tools as appropriate were used to assess anxiety, anger, and depression respectively among our respondents. Results: Severe anxiety (68.8%) followed by moderate depression (60.5%) and moderate anger (56.9%) were the most common mental health challenges experienced by low-income earners in Bushenyi district. Awareness of mental healthcare increased with the age of respondents in both males and females. A linear relationship was observed with age and depression (r = 0.154, P = 0.014) while positive correlations were observed between anxiety and anger (r = 0.254, P < 0.001); anxiety and depression (r = 0.153, P = 0.015) and anger and depression (r = 0.153, P = 0.015). Conclusion: The study shows the importance of mental health awareness in low resource settings during the current COVID-19 pandemic. Females were identified as persons at risk to mental depression, while anger was highest amongst young males.

Using ecological momentary assessment to enhance irritability phenotyping in a transdiagnostic sample of youth

Irritability is a transdiagnostic symptom dimension in developmental psychopathology, closely related to the Research Domain Criteria (RDoC) construct of frustrative nonreward. Consistent with the RDoC framework and calls for transdiagnostic, developmentally-sensitive assessment methods, we report data from a smartphone-based, naturalistic ecological momentary assessment (EMA) study of irritability. We assessed 109 children and adolescents (Mage = 12.55 years; 75.20% male) encompassing several diagnostic groups – disruptive mood dysregulation disorder (DMDD), attention-deficit/hyperactivity disorder (ADHD), anxiety disorders (ANX), healthy volunteers (HV). The participants rated symptoms three times per day for 1 week. Compliance with the EMA protocol was high. As tested using multilevel modeling, EMA ratings of irritability were strongly and consistently associated with in-clinic, gold-standard measures of irritability. Further, EMA ratings of irritability were significantly related to subjective frustration during a laboratory task eliciting frustrative nonreward. Irritability levels exhibited an expected graduated pattern across diagnostic groups, and the different EMA items measuring irritability were significantly associated with one another within all groups, supporting the transdiagnostic phenomenology of irritability. Additional analyses utilized EMA ratings of anxiety as a comparison with respect to convergent validity and transdiagnostic phenomenology. The results support new measurement tools that can be used in future studies of irritability and frustrative nonreward.

Cardiovascular reactivity as a measure of irritability in a transdiagnostic sample of youth: Preliminary associations

OBJECTIVES

Irritability is a transdiagnostic symptom in developmental psychopathology, conceptualized as a low threshold for frustration and increased proneness to anger. While central to emotion regulation, there is a vital need for empirical studies to explore the relationship between irritability and underlying physiological mechanisms of cardiovascular arousal.

METHODS

We examined the relationship between irritability and cardiovascular arousal (i.e., heart rate [HR] and heart rate variability [HRV]) in a transdiagnostic sample of 51 youth (M = 12.63 years, SD = 2.25; 62.7% male). Data was collected using the Empatica E4 during a laboratory stop-signal task. In addition, the impact of motion activity, age, medication, and sleep on cardiovascular responses was explored.

RESULTS

Main findings showed that irritability was associated with increased HR and decreased HRV during task performance.

CONCLUSIONS

Findings support the role of peripheral physiological dysregulation in youth with emotion regulation problems and suggest the potential use of available wearable consumer electronics as an objective measure of irritability and physiological arousal in a transdiagnostic sample of youth.

Interaction of irritability and anxiety on emotional responding and emotion regulation: a functional MRI study

BACKGROUND

Irritability and anxiety frequently co-occur in pediatric populations. Studies separately looking at the neural correlates of these symptoms have identified engagement of similar neural systems - particularly those implicated in emotional processing. Both irritability and anxiety can be considered negative valence emotional states that might relate to emotion dysregulation. However, previous work has not examined the neural responding during the performance of an emotion regulation task as a function of interaction between irritability and anxiety simultaneously.

METHODS

This fMRI study involved 155 participants (90 with significant psychopathologies and 92 male) who performed the Affective Stroop Task, designed to engage emotion regulation as a function of task demands. The Affective Reactivity Index (ARI) was used to index irritability and the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to index anxiety.

RESULTS

Levels of irritability, but not anxiety, was positively correlated with responses to visual images within the right rostro-medial prefrontal cortex and left anterior cingulate cortex during view trials. The second region of ventral anterior cingulate cortex showed a condition-by-emotion-by-ARI score-by-SCARED score interaction. Specifically, anxiety level was significantly correlated with a decreased differential BOLD response to negative relative to neutral view trials but only in the presence of relatively high irritability.

CONCLUSIONS

Atypical maintenance of emotional stimuli within the rostro-medial prefrontal cortex may exacerbate the difficulties faced by adolescents with irritability. Moreover, increased anxiety combined with significant irritability may disrupt an automatic emotional conflict-based form of emotion regulation that is particularly associated with the ventral anterior cingulate cortex.

Neural correlates of extinguished threat recall underlying the commonality between pediatric anxiety and irritability

BACKGROUND

Anxiety and irritability frequently co-occur in youth and are mediated by aberrant threat responses. However, empirical evidence on neural mechanisms underlying this co-occurrence is limited. To address this, we apply data-driven latent phenotyping to data from a prior report of a well-validated threat extinction recall fMRI paradigm.

METHODS

Participants included 59 youth (28 anxiety disorder, 31 healthy volunteers; Mage=13.15 yrs) drawn from a transdiagnostic sample of 331 youth, in which bifactor analysis was conducted to derive latent factors representing shared vs. unique variance of dimensionally-assessed anxiety and irritability. Participants underwent threat conditioning and extinction. Approximately three weeks later, during extinction recall fMRI, participants made threat-safety discriminations under two task conditions: current threat appraisal and explicit recall of threat contingencies. Linear mixed-effects analyses examined associations of a "negative affectivity" factor reflecting shared anxiety and irritability variance with whole-brain activation and task-dependent amygdala connectivity.

RESULTS

During recall of threat-safety contingencies, higher negative affectivity was associated with greater prefrontal (ventrolateral/ventromedial, dorsolateral, orbitofrontal), motor, temporal, parietal, and occipital activation. During threat appraisal, higher negative affectivity was associated with greater amygdala-inferior parietal lobule connectivity to threat/safety ambiguity.

LIMITATIONS

Sample included only healthy youth and youth with anxiety disorders. Results may not generalize to other diagnoses for which anxiety and irritability are also common, and our negative affectivity factor should be interpreted as anxiety disorders with elevated irritability. Reliability of some subfactors was poor.

CONCLUSIONS

Aberrant amygdala-prefrontal-parietal circuitry during extinction recall of threat-safety stimuli may be a mechanism underlying the co-occurrence of pediatric anxiety and irritability.

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.

Attention bias to negative versus non-negative faces is related to negative affectivity in a transdiagnostic youth sample

This study identified a shared pathophysiological mechanism of pediatric anxiety and irritability. Clinically, anxiety and irritability are common, co-occurring problems, both characterized by high-arousal negative affective states. Behaviorally, anxiety and irritability are associated with aberrant threat processing. To build on these findings, we examined eye-tracking measures of attention bias in relation to the unique and shared features of anxiety and irritability in a transdiagnostic sample of youth (n = 97, 58% female, M_age = 13.03, SD_age = 2.82). We measured attention bias to negative versus non-negative emotional faces during a passive viewing task. We employed bifactor analysis to parse the unique and shared variance of anxiety and irritability symptoms from self- and parent-report questionnaires. Negative affectivity is the derived latent factor reflecting shared variance of anxiety and irritability. We found that higher negative affectivity was associated with looking longer at negative versus non-negative faces, reflecting a shared mechanism of anxiety and irritability. This finding suggests that modification of elevated attention to negative emotional faces may represent a common potential treatment target of anxiety and irritability.

Measuring Irritability in Early Childhood: A Psychometric Evaluation of the Affective Reactivity Index in a Clinical Sample of 3- to 8-Year-Old Children

The parent-report Affective Reactivity Index (ARI-P) is the most studied brief scale specifically developed to assess irritability, but relatively little is known about its performance in early childhood (i.e., ≤8 years). Support in such populations is particularly important given developmental shifts in what constitutes normative irritability across childhood. We examined the performance of the ARI-P in a diverse, treatment-seeking sample of children ages 3 to 8 years (N = 115; mean age = 5.56 years; 58.4% from ethnic/racial minority backgrounds). In this sample, confirmatory factor analysis supported the single-factor structure of the ARI-P previously identified with older youth. ARI-P scores showed large associations with another irritability index, as well as small-to-large associations with aggression, anxiety, depression, and attention problems, supporting the convergent and concurrent validity of the ARI-P when used with children in this younger age range. Findings support the ARI-P as a promising parent-report tool for assessing irritability in early childhood, particularly in clinical samples.

Psychiatric comorbidity and social adjustment difficulties in children with disruptive mood dysregulation disorder: A national epidemiological study

BACKGROUND

We examined correlates, psychiatric comorbidities, and social adjustment difficulties in children with disruptive mood dysregulation disorder (DMDD) from a national epidemiological study in Taiwan.

METHODS

The sample consisted of 4816 children, who were 3^rd, 5^th, and 7^th graders from schools randomly chosen based on the urbanization level in a recent national survey of childhood mental disorders. Among the 4816 children (2520 boys, 52.3%) interviewed using the Kiddie epidemiologic version of the Schedule for Affective Disorders and Schizophrenia (K-SADS-E) for the DSM-5, 30 children were diagnosed as DMDD (23 boys, 76.7%). They and their parents also reported on the Social Adjustment Inventory for Children and Adolescents (SAICA). We conducted regressions for survey data that controlled for stratification and clustering.

RESULTS

The weighted prevalence of DMDD was 0.3~0.76% in Taiwanese children. Lower parental educational levels, male predominance, higher psychiatric comorbidities, and worse self-report school functions (e.g., more behavioral problems with peers) were observed in children with DMDD than those without. Additional analyses revealed that oppositional defiant disorder (ODD) but not DMDD was related to conduct disorder. Children with ODD with or without DMDD had more problems regarding attitudes toward school, academic performance, and parent-child interaction at home than those with DMDD-only.

LIMITATIONS

Small sample size of DMDD.

CONCLUSIONS

DMDD is a rare disorder in the community. Children with DMDD had more psychiatric comorbidities, and subjectively experienced more difficulties than those without. DMDD and ODD both resulted in severe impairment yet in different domains.

Differentiating irritable mood and disruptive behavior in adults

Introduction

Irritability has both mood and behavioral manifestations. These frequently co-occur, and it is unclear to what extent they are dissociable domains. We used confirmatory factor analysis and external validators to investigate the independence of mood and behavioral components of irritability.

Methods

The sample comprised 246 patients (mean age 45 years; 63% female) from four outpatient programs (depression, anxiety, bipolar, and schizophrenia) at a tertiary hospital. A clinical instrument rated by trained clinicians was specifically designed to capture irritable mood and disruptive behavior dimensionally, as well as current categorical diagnoses i.e., intermittent explosive disorder (IED); oppositional defiant disorder (ODD); and an adaptation to diagnose disruptive mood dysregulation disorder (DMDD) in adults. Confirmatory factor analysis (CFA) was used to test the best fitting irritability models and regression analyses were used to investigate associations with external validators.

Results

Irritable mood and disruptive behavior were both frequent, but diagnoses of disruptive syndromes were rare (IED, 8%; ODD, 2%; DMDD, 2%). A correlated model with two dimensions, and a bifactor model with one general dimension and two specific dimensions (mood and behavior) both had good fit indices. The correlated model had root mean square error of approximation (RMSEA) = 0.077, with 90% confidence interval (90%CI) = 0.071-0.083; comparative fit index (CFI) = 0.99; and Tucker-Lewis index (TLI) = 0.99, while the bifactor model had RMSEA = 0.041; CFI = 0.99; and TLI = 0.99 respectively). In the bifactor model, external validity for differentiation of the mood and behavioral components of irritability was also supported by associations between irritable mood and impairment and clinical measures of depression and mania, which were not associated with disruptive behavior.

Conclusions

Psychometric and external validity data suggest both overlapping and specific features of the mood vs. disruptive behavior dimensions of irritability.

A Prospective Study of Rumination and Irritability in Youth

Although youth irritability is linked with substantial psychiatric morbidity and impairment, little is known about how personal characteristics influence its course. In this study we examined the prospective associations between angry and depressive rumination and irritability. A sample of 165 school pupils aged 12-14 years were assessed at two time points six months apart. They completed measures of irritability at Times 1 and 2 and depressive and angry rumination at Time 1. In line with our hypotheses, we found that angry rumination is significantly associated with irritability six months later, over and above baseline irritability and depressive rumination. The present findings suggest angry rumination is relevant to the genesis of irritability in adolescents, and point to possible routes for prevention and early intervention.

Feasibility and acceptability of a brief cognitive-behavioral group intervention for chronic irritability in youth

Chronic irritability is a core feature of oppositional defiant disorder (ODD) and disruptive mood dysregulation disorder (DMDD), but few irritability-specific interventions have been tested. Existing evidence-based treatments for disruptive behavior problems offer a strong template. This pilot study was conducted to develop and evaluate a brief irritability-specific module of a validated cognitive-behavioral group intervention for children (Stop Now And Plan (SNAP) Program). Stop now and plan for irritability (I-SNAP) retained core elements of SNAP in a shortened 6-week format. Community families with irritable children (M = 8.44 years, SD = 1.42) were recruited for parent and child emotion regulation skills groups. Of 18 children enrolled (72% male), 14 completed (78%). Half of children attended all six sessions, though homework compliance was lower. All parents reported favorable impressions and would recommend I-SNAP to others. Significant improvements were seen from pre- to post-treatment across parent-reported irritability, ODD symptoms, emotion regulation, and disciplinary effectiveness. This pilot study provides initial support suggesting I-SNAP may be feasible to implement and acceptable to parents. In addition, pilot analyses demonstrated that this brief group intervention was associated with positive outcomes consistent with treatment targets. This preliminary evidence supports the need for further research to assess I-SNAP's effects on irritability relative to control groups.

Developmental pathways to social anxiety and irritability: The role of the ERN

Early behaviors that differentiate later biomarkers for psychopathology can guide preventive efforts while also facilitating pathophysiological research. We tested whether error-related negativity (ERN) moderates the link between early behavior and later psychopathology in two early childhood phenotypes: behavioral inhibition and irritability. From ages 2 to 7 years, children (n = 291) were assessed longitudinally for behavioral inhibition (BI) and irritability. Behavioral inhibition was assessed via maternal report and behavioral responses to novelty. Childhood irritability was assessed using the Child Behavior Checklist. At age 12, an electroencephalogram (EEG) was recorded while children performed a flanker task to measure ERN, a neural indicator of error monitoring. Clinical assessments of anxiety and irritability were conducted using questionnaires (i.e., Screen for Child Anxiety Related Disorders and Affective Reactivity Index) and clinical interviews. Error monitoring interacted with early BI and early irritability to predict later psychopathology. Among children with high BI, an enhanced ERN predicted greater social anxiety at age 12. In contrast, children with high childhood irritability and blunted ERN predicted greater irritability at age 12. This converges with previous work and provides novel insight into the specificity of pathways associated with psychopathology.

Neural and behavioral correlates of inhibitory control in youths with varying levels of irritability

BACKGROUND

Irritability, a relatively lowered threshold for anger, is prevalent in typically and atypically developing youths. Inhibitory control, the ability to suppress behaviors counter to goals, is essential for regulating emotions, including anger. Understanding how irritability relates to behavioral and neural markers of inhibitory control may inform interventions.

METHODS

Youths (N=52; mean age=13.78) completed a Flanker task on an iPad to measure behavioral correlates of inhibitory control; a subsample (n=19; mean age=13.21) additionally completed a similar task while undergoing fMRI acquisition to evaluate inhibitory control on a neural level. Irritability was measured using the Affective Reactivity Index. Associations between irritability and inhibitory control were evaluated behaviorally (via Pearson correlations), and neurally (via ANCOVAs with whole-brain activation and amygdala connectivity).

RESULTS

fMRI results indicated that higher levels of irritability were associated with aberrant activation (in middle frontal gyrus, amygdala/parahippocampal gyrus, anterior cingulate, lentiform nucleus/striatum) and left amygdala connectivity (with middle temporal gyrus, parahippocampal gyrus, posterior cingulate, fusiform gyrus, and thalamus). Behavioral results were mixed.

LIMITATIONS

Longitudinal studies are needed to characterize changes in neural circuitry and delineate whether the brain profiles precede or are a consequence of symptoms. Larger samples powered to examine multiple irritability-related symptom dimensions will be necessary to elucidate shared vs. disorder-specific irritability mechanisms.

CONCLUSIONS

Findings suggest that pediatric irritability may be related to neural processes involving inhibitory control. Further, findings underscore the importance of neuroimaging in investigating symptom dimensions such as irritability, as neuroimaging may be more sensitive in detecting underlying abnormalities compared to behavioral data alone.

Multi-method assessment of irritability and differential linkages to neurophysiological indicators of attention allocation to emotional faces in young children

Facilitated attention toward angry stimuli (attention bias) may contribute to anger proneness and temper outbursts exhibited by children with high irritability. However, most studies linking attention bias and irritability rely on behavioral measures with limited precision and no studies have explored these associations in young children. The present study explores irritability-related attention biases toward anger in young children (N = 128; ages 4-7 years) engaged in a dot-probe task with emotional faces, as assessed with event-related brain potential (ERP) indices of early selective attention and multi-method assessment of irritability. Irritability assessed via semi-structured clinical interview predicted larger anterior N1 amplitudes to all faces. In contrast, irritability assessed via a laboratory observation paradigm predicted reduced P1 amplitudes to angry relative to neutral faces. These findings suggest that altered early attentional processing occurs in young children with high irritability; however, the nature of these patterns may vary with methodological features of the irritability assessments. Future investigations using different assessment tools may provide greater clarity regarding the underlying neurocognitive correlates of irritability. Such studies may also contribute to the ongoing debates about how to best define and measure irritability across the developmental spectrum in a manner that is most informative for linkage to neural processes.

Attention shifting in the context of emotional faces: Disentangling neural mechanisms of irritability from anxiety

BACKGROUND

Irritability predicts concurrent and prospective psychiatric disorders across the lifespan. Anxiety commonly co-occurs with irritability, and such comorbidity complicates care. Understanding the mechanisms of comorbid traits is necessary to inform treatment decisions. This study aimed to disentangle neural mechanisms of irritability from anxiety in the context of attentional shifting toward and away from emotional faces in youths from treatment-seeking families.

METHODS

Youths (N = 45), mean age = 14.01 years (standard deviation = 1.89) completed a dot-probe task during functional magnetic resonance imaging acquisition. Whole-brain activation analyses evaluated the effect of irritability on neural reactivity in the context of varying attentional shifting toward and away from emotional faces, both depending on and above and beyond anxiety (i.e., with anxiety as [a] a moderator and [b] a covariate, respectively).

RESULTS

Higher irritability levels related to distinct task-related patterns of cuneus activation, depending on comorbid anxiety levels. Increased irritability also related to distinct task-related patterns of parietal, temporal, occipital, and cerebellar activation, controlling for anxiety. Overall, youths with higher levels of irritability evinced more pronounced fluctuations in neural reactivity across task conditions.

CONCLUSION

The present study contributes to a literature delineating the unique and shared neural mechanisms of overlapping symptom dimensions, which will be necessary to ultimately build a brain- and behavior-based nosology that forms the basis for more targeted and effective treatments.

Comorbid anxiety and irritability symptoms and their association with cognitive functioning in children with ADHD

Anxiety and irritability symptoms frequently co-occur in children with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aims to investigate whether irritability and anxiety are uniquely associated with performance on measures of cognitive functioning in children with ADHD and whether these associations hold when accounting for confounding variables. Baseline data was used from a randomised controlled trial of cognitive behavioural therapy for anxiety in children with ADHD (N = 219, 8-13 years). Anxiety was assessed using the child- and parent-reported Spence Children's Anxiety Scale, while irritability was assessed using the parent-reported Affective Reactivity Index. Children completed the National Institutes of Health Toolbox - Cognition Battery. Higher symptoms of anxiety were uniquely associated with performance on the Dimensional Card Change Sort Test (β = -2.75, confidence interval (CI) [-4.97, -.52], p = .02) and the List Sort Working Memory Test (β = -2.57, CI [-4.43, -.70], p = .01), while higher symptoms of irritability were negatively associated with Picture Vocabulary Test (β = -2.00, CI [-3.83, -.16], p = .03). These associations did not survive correction for multiple comparisons. There was little evidence of an association between anxiety or irritability symptoms and cognitive functioning. Frequent co-occurrence of anxiety and irritability suggests clinicians working with children with ADHD should assess co-morbid symptom profiles to inform the provision of optimum care.

Irritability and its relationships with psychological symptoms in adolescents with migraine: a case-control study

OBJECTIVE

The aim of this study was to investigate self- and parent-reported irritability in adolescents with migraine and to evaluate the relationship between self- and parent-reported irritability and psychological symptoms in adolescents with migraine.

METHODS

The sample of this single-center cross-sectional case-control study consisted of 71 adolescents with migraine (who were followed in a pediatric neurology clinic) and their parents. The control group consisted of 41 age- and sex-matched healthy adolescents and their parents.

RESULTS

It was observed that there were significant differences in both self- (p < 0.001) and parent-reported (p < 0.001) irritability scores between the migraine and control groups. When the two groups were compared in terms of psychological symptoms, adolescents with migraine had significantly higher levels of anxiety (p < 0.001) and emotional problems (p < 0.001) than their healthy peers. This significant difference persisted even after controlling for confounding factors such as age, gender, family income, and maternal and paternal educational level. Our results revealed a moderate positive correlation between irritability scores and anxiety scores (r = 0.522, p < 0.001) and between irritability scores and emotional/behavioral problem scores (r = 0.487, p < 0.001) in the migraine group. In addition to these results, the odds ratios of self-reported irritability scores and emotional problem scores for migraine were 1.31 and 1.41, respectively.

CONCLUSION

The levels of anxiety, emotional/behavioral, and attention deficit/hyperactivity problems increased as the levels of irritability increased in the migraine group, suggesting that the psychosocial functionality of these adolescents may be impaired. Therefore, all adolescents with migraine (especially those with irritability) may have need of psychosocial support.