Irritability and Limited Prosocial Emotions/Callous-Unemotional Traits in Elementary-School-Age Children

Peer functioning difficulties may exacerbate symptoms of attention-deficit/hyperactivity disorder and irritability over time: a temporal network analysis

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) have been consistently found to experience impairments in peer functioning. Irritability is highly prevalent in children with ADHD and may worsen social impairments given the frequent temper outbursts and low frustration tolerance characterizing irritability. However, it is still unclear how ADHD and irritability symptoms interact with peer functioning difficulties over time. Assessing these temporal dynamics using a novel longitudinal approach (i.e., temporal network analysis) may reveal precise targets for intervention.

METHODS

This study investigates the dynamic associations between ADHD symptoms, irritability, and peer functioning in a community sample of 739 children (ages 8-11 years, Mage = 10.06 [SD = 0.59], 47.77% females) assessed at three timepoints, 6 months apart, in a school-based study. Parents reported their child's ADHD symptoms using the Swanson, Nolan, and Pelham Rating Scale (SNAP-IV), and irritability symptoms using the Child Behavior Checklist (CBCL) irritability items. Children's peer functioning (i.e., peer acceptance, peer rejection, number of friendships, and victimization) was measured via peer nomination. To estimate the longitudinal associations between the variables, we built a graphical vector autoregression model for panel data.

RESULTS

The longitudinal network highlighted that poor peer functioning contributed to increases in symptoms over time. Specifically, (1) physical victimization predicted increases in inattention, hyperactivity, and irritability; (2) peer rejection predicted increases in inattention, which in turn predicted increases in irritability; (3) peer acceptance predicted decreases in inattention and irritability; and (4) higher numbers of mutual friendships increased inattention.

CONCLUSIONS

These results suggest that a negative social environment involving physical bullying and rejection may aggravate ADHD and irritability symptoms. Conversely, positive social interactions, such as being liked by peers, may improve inattention and irritability symptoms. Fostering social-emotional skills and positive social interactions and environments in children with ADHD and irritability may be a promising target for future interventions to reduce symptoms.

How are irritability and anhedonia symptoms linked? A network approach

BACKGROUND

Anhedonia and irritability are two prevalent symptoms of major depressive disorder (MDD) that predict greater depression severity and poor outcomes, including suicidality. Although both symptoms have been proposed to result from paradoxical reward processing dysfunctions, the interactions between these symptoms remain unclear. Anhedonia is a multifaceted symptom reflecting impairments in multiple dimensions of reward processing (e.g., pleasure, desire, motivation, and effort) across distinct reward types (e.g., food, sensory experiences, social activities, hobbies) that may differentially interact with irritability. This study investigated the complex associations between anhedonia and irritability using network analysis.

METHOD

Participants (N = 448, Mage = 33.29, SD = 14.58) reported their symptoms of irritability on the Brief Irritability Test (Holtzman et al., 2015) and anhedonia (i.e., pleasure, desire, motivation, and effort dimensions across four reward types) on the Dimensional Anhedonia Rating Scale (Rizvi et al., 2015). A regularized Gaussian Graphical Model was built to estimate the network structure between items.

RESULTS

Irritability was negatively related to willingness to expand effort to obtain food/drinks (estimate = -0.18), social activities (-0.13), and hobbies (-0.12) rewards. Irritability was positively associated with a desire for food/drinks (0.12).

LIMITATIONS

Only a small proportion (5.8%) of our sample was clinical and the study design was cross-sectional.

CONCLUSION

A specific link between irritability and the effort dimension of the hedonic response across three reward types was identified. Investigating effort expenditure deficits with experimental paradigms may help us understand the mechanisms underlying the comorbidity between irritability and anhedonia in the context of MDD.

Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

The Impact of Callous-Unemotional Traits on Achievement, Behaviors, and Relationships in School: A Systematic Review

Disruptive behavior disorders (DBDs) are associated with significant academic, behavioral, and relationship challenges in the school setting. Children with co-occurring DBDs and callous-unemotional (CU) traits show a distinct pattern of early starting, chronic, and aggressive disruptive behavior and are resistant to traditional DBD interventions. There is growing evidence that CU traits have important consequences for children's school functioning. The purpose of this systematic review is to synthesize research on CU traits in school with a focus on academics, relationships, and behavior. We searched PsycINFO, PubMed, and Education Full-Text to identify 37 empirical studies that met inclusionary criteria. Findings suggest that CU traits are associated with poor academic performance, high levels of aggression and conduct problems, and difficulty forming relationships at school, often above and beyond the impact of DBDs alone. Findings and future directions are discussed including how the current study can support key stakeholders in promoting the success of students with elevated CU traits.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Reciprocal relations between dimensions of Oppositional defiant problems and callous-unemotional traits

Although irritability, headstrong/defiant behavior, and callous-unemotional traits (CU traits) often co-occur, the prospective associations between them are not well known. A general population sample of 622 children was followed up yearly from ages 3 to 12 years and assessed using dimensional measures of irritability, headstrong/defiant, and CU traits with teacher provided information. A random intercept cross-lagged panel model, accounting for all unmeasured time-invariant confounding using the children as their own controls, revealed cross-lagged reciprocal associations between increased headstrong/defiant and increased CU traits at all ages and a unidirectional association from headstrong/defiant to irritability. The findings are consistent with headstrong/defiant behavior and CU traits mutually influencing each other over time and headstrong/defiant behavior enhancing irritability. School-based intervention and prevention programs should take these findings into consideration. They also suggest that irritability acts as a distinct developmental dimension of headstrong/defiant and callous-unemotional behaviors and needs to be addressed independently.

The Impact of Irritability and Callous Unemotional Traits on Reward Positivity in Youth with ADHD and Conduct Problems

Children with attention-deficit/hyperactivity disorder (ADHD) and conduct problems exhibit significant variability in functioning and treatment response that cannot be fully accounted for by differences in symptom severity. Reward responsivity (RR) is a potential transdiagnostic means to account for this variability. Irritability and callous-unemotional (CU) traits moderate associations between both ADHD and conduct problems with multiple realms of functioning. Both are theorized to be associated with RR, but associations in clinical samples are unknown. In 48 youth ages 5-12 with ADHD referred for treatment of conduct problems, we examined RR using a guessing task where participants select a door icon to win and lose money. Analyses focused on the reward positivity (RewP) event-related potential in response to gain and loss feedback, which reliably peaks approximately 300 ms after feedback. Frequentist and Bayesian approaches assessed main effects of ADHD, Conduct Disorder (CD) and non-irritable Oppositional Defiant Disorder (ODD) symptoms with RR, plus interactions between symptoms and affective dimensions (irritability, CU). CD and ODD were hypothesized to be associated with altered RR, with irritability and CU moderating these associations. Across models, a reliable CD x irritability interaction emerged, indicating enhanced RewP when irritability was elevated and CD symptoms were low. CU did not moderate any associations with RR, and little support was found for associations between RR and other symptom domains. As neural response to reward varied with levels of irritability and CD symptoms, RR may hold potential as a clinically-relevant biomarker in youth with ADHD and conduct problems.

The significance of limited prosocial emotions among externalizing disorders in children

Limited Prosocial Emotion (LPE) specifier of conduct disorder (CD) includes lack of remorse or guilt, callousness/lack of empathy, unconcern about performance, and shallow/deficient affect. Given the relatively recent inclusion of the LPE specifier in the Diagnostic and Statistical Manual, fundamental information is still unknown about LPE, such as how common the different domains are, how much they overlap with one another, whether they predict unique variance from each other, and the potential for the LPE specifier as a transdiagnostic facet of externalizing problems. Caregivers (n = 1,50) of children (M_age = 8.42, SD = 2.31) completed a questionnaire assessing individual LPE domains and measures of externalizing symptoms. Results showed that LPE specifier domains were highly related but separable. All LPEs were uniquely associated with oppositional defiant disorder (ODD), CD, and overall impairment after controlling for other LPE items, child sex, and ADHD symptoms. Being unconcerned about performance, emotionally manipulative, and having shallow/deficient affect were uniquely associated with ADHD while controlling for ODD and CD symptomatology. Our findings fit with the historical conceptualization of LPE as a unidimensional construct and contributes to the growing evidence of the potential utility of assessing LPE across externalizing disorders in children. Future research should look to replicate and extend our findings in clinical samples of youth.

Is Irritability a Top Problem in Youth Mental Health Care? A Multi-informant, Multi-method Investigation

Irritability is often described as a common problem affecting youth referred for mental health services; however, little is known about the prevalence and nature of irritability as a focus of treatment. We examined assessment data from a diverse sample of youths (N = 206; ages 7-15; 52% male, 48% female; 33% White, 27% Black, 25% Latinx) referred for outpatient treatment of emotional and behavioral concerns. Caregivers and youths completed nomothetic (standardized checklist) and idiographic (free response) measures at intake. Irritability was identified as a top problem (TP) in 58% of cases, commonly reported by caregivers (38%), youths (42%), or both (23%)-rates that were significantly greater than those of other TP domains (depression, anxiety, ADHD, conduct, and defiance). Further analyses identified clinical correlates of irritability TPs, with results supporting the incremental utility of multiple informants and methods. Findings suggest that irritability is among the most common problems for which families seek youth treatment.

Examination of the importance of anger/irritability and limited prosocial emotion/callous-unemotional traits to understand externalizing symptoms and adjustment problems in adolescence: A 10-year longitudinal study

Objective

Within a longitudinal study (10-year follow-up), we aim to examine the role of anger/irritability and limited prosocial emotion/callous-unemotional traits in predicting externalizing symptoms and adjustment problems in individuals formerly in youth residential care institutions.

Method

These dimensions were assessed in 203 young adults, with baseline assessments during youth residential care and a follow-up 10 years later.

Results

In general, emotional problems and psychopathological symptoms did not reduce over time. Analyses of regression revealed that a younger age at baseline, anger/irritability both at baseline assessment, and regarding their aggravation over time refer to significant predictors of the level of externalizing symptoms at 10-year follow-up (R ² = 0.431) and the worsening of externalizing symptoms over time (R ² = 0.638). Anger/irritability has been observed to be a significant predictors of both the level of adjustment problems at 10-year follow-up (R ² = 0.471) and its worsening over time (R ² = 0.656).

Discussion

Our results suggest that dysregulation of anger/irritability is a key factor in the prediction of long-term externalizing symptoms and adjustment problems as well as its worsening over time. Possible implications for intervention and prevention are discussed.

The Importance of Assessing Impairment Associated With Limited Prosocial Emotions

Limited prosocial emotions (LPE) are characterized by a lack of remorse or guilt, callousness/lack of empathy, being unconcerned about performance, and shallow/deficient affect. While previous research has largely focused on the presence or absence of LPE in youth, there is considerable evidence that symptom presence/absence and symptom impairment are separable dimensions, where impairment often is found to play a significant, unique role in assessing child psychopathology. The current study utilized a newly developed questionnaire with the purpose of exploring its psychometric properties and better understand the dual and potentially differential role LPE symptom presence and LPE-related impairment have in youth. Mothers (n = 265) of children (M_age = 8.04, SD = 2.07) completed questionnaires assessing LPE impairment, LPE symptoms, externalizing disorder symptoms, and functional impairment. Results demonstrated strong support for the psychometric properties of the newly developed measure of LPE impairment. Importantly, LPE-related impairment uniquely predicted all impairment domains above-and-beyond the effects of LPE symptoms, oppositional defiant disorder, and CD symptoms (as well as child age and sex covariates). Moreover, youth in the top 25th percentile on both LPE symptoms and LPE-related impairment (compared to youth only in the top 25th percentile in LPE symptoms) had greater mean externalizing symptoms and functional impairment. The preliminary evidence provided suggests researchers and clinicians may benefit from assessing both LPE symptoms and LPE-related impairment when attempting to identify youth with high levels of conduct problem symptoms and/or psychosocial impairment. Future research should aim to replicate and expand our findings to other clinical populations.

Identifying the Inter-Domain Relations Among ODD, CD, and CU Traits in Preschool Children Using Network Analysis

Oppositional defiant disorder (ODD) and conduct disorder (CD) are two of the most common forms of disruptive behavior disorders during childhood. Callous-unemotional (CU) traits are an important factor in understanding the presentation of these externalizing forms of psychopathology. ODD, CD, and CU traits are highly related constructs, yet little work has examined how these externalizing forms of psychopathology are related at the domain level. The current study utilized network analysis to identify the distinct domains that explain the associations among ODD, CD, and CU traits. In a sample of 104 preschoolers (M age = 4.76), results demonstrated that the symptom domains of (a) angry/irritable mood and argumentative/defiant behavior, (b) aggression to people and animals, and (c) callousness were the primary bridge domains for ODD, CD, and CU traits, respectively. Findings of the current study offer a more nuanced insight into the relations amongst ODD, CD, and CU traits. Identification of bridge symptom domains can inform intervention practices by targeting specific symptom domains that are contributing to the maintenance of such aggressive and disruptive behaviors.

Context-dependent irritability in Attention Deficit/Hyperactivity Disorder: correlates and stability of family-restricted versus cross-situational temper outbursts

BACKGROUND

Impairing irritability is highly prevalent in children with attention deficit/hyperactivity disorder (ADHD), although manifestations of irritability are not necessarily present in all settings (home, school, with peers). At the moment, little is known about the relative prevalence, stability, and etiologies of contextual versus cross-situational manifestations of irritability in ADHD. In this study, levels of dysfunctional parenting practices and sleep problems were compared in irritable versus nonirritable children with ADHD, in cases of family-restricted versus cross-situational irritability, and examined as predictors of irritability levels over a one-year interval. Stability of irritability manifestations over time was investigated, and prevalence of cross-situational disruptive mood dysregulation disorder (DMDD) versus 'family-restricted' DMDD was compared.

METHOD

One hundred and seventy children with ADHD (age 6-11) were examined. Parents completed a semi-structured interview and questionnaire to assess irritability, and parent-report questionnaires were used to evaluate parenting practices and sleep problems. Questionnaires were completed for a second time after a one-year interval.

RESULTS

Parenting practices were more dysfunctional in the irritable group compared to the nonirritable group, while sleep problems did not differ between these two groups. Levels of parenting practices and sleep problems did not predict later irritability after correction for multiple comparison nor did they differ between the family-restricted and cross-situational irritable groups. Finally, family-restricted irritability was as prevalent and as stable over time as cross-situational irritability and family-restricted DMDD as prevalent as cross-situational DMDD.

CONCLUSIONS

Factors associated with contextual versus cross-situational manifestations of irritability in ADHD remain elusive. More subtle measures of parenting practices should be considered, including psychological control or accommodation, and other constructs such as social inhibition. Despite not being captured by current nosography, severe forms of family-restricted irritability may be as prevalent as severe forms of cross-situational irritability.

The Impact of Persistent Irritability on the Medication Treatment of Paediatric Attention Deficit Hyperactivity Disorder

This study compares the efficacy and tolerability of central nervous system (CNS) stimulants in children with attention deficit hyperactivity disorder (ADHD) with and without prominent irritability (IRR) over the course of 30 months. This is a secondary analysis of a study examining growth patterns in medication naïve children with ADHD subsequently treated with CNS stimulants (predominantly OROS-Methylphenidate, up to 54 mg per day) for 30 months. Participants had to meet full diagnostic criteria for ADHD and been treated with CNS stimulants for under 30 days. Children were classified as IRR if they were rated as pretty much or very much on either of the "often angry" or easily annoyed" items plus "lose temper," items of the Disruptive Behavior Disorders Rating Scale (DBDRS). Structured ratings of ADHD symptoms, impairment, side effects, and symptoms of oppositional defiant disorder (ODD) were collected every 2-12 weeks for the duration of the study. Medication use was measured by pill count and parent report. The IRR group comprised 28% of all participants. The IRR group had significantly higher levels of ADHD and ODD symptoms, impairment, and side effects ratings at baseline. In the IRR group, ODD symptoms, emotional lability, and impairment significantly decreased for participants with higher medication use. Total side effects increased for non-IRR participants with higher medication use. Emotional side effects decreased for IRR participants with higher medication use. Central nervous system stimulants were a tolerable and efficacious treatment in treatment naïve youth with ADHD with irritability. Clinical Trials Registration: NCT01109849.

Joining the pieces in childhood irritability: Distinct typologies predict conduct, depressive, and anxiety symptoms

This study utilised a person-centered approach to understand childhood irritability as a transdiagnostic feature of psychopathology. Latent profile analysis was employed within a community sample (n = 93) of 9-11 year olds to identify typologies of self-regulation capabilities, positive wellbeing characteristics of hope and flourishing, and social functioning that cluster with children's irritability to mitigate risk for psychopathology symptoms. Three distinct profiles of youth were derived, High Irritability/Low Self-Regulation of Negative Emotion (9%), Moderate Irritability/Low Behavioural Control (34%) and Low Irritability/High Positive Wellbeing Characteristics (57%). Profiles were empirically validated and differentially related to symptoms of anxiety, depression and conduct problems. Notably, High Irritability/Low Self-Regulation of Negative Emotion children were characterised by the highest levels of irritability and peer problems and the lowest self-regulation of negative emotion, prosocial behaviours, hope and flourishing relative to children within the other profiles, pointing to the potential utility of future targeted, transdiagnostic interventions. Within our community-based sample, a protective profile of Low Irritability/High Positive Wellbeing Characteristics children were also described by the lowest levels of irritability and peer problems and the highest positive and negative emotion self-regulation, behavioural control, prosocial behaviours, hope and flourishing. Findings demonstrate that different levels of irritability severity cluster with different self-regulation capabilities and wellbeing characteristics and predict risk for different types of psychopathology. Targeted interventions should seek to address children's irritability alongside self-regulation and positive wellbeing characteristics to further mitigate risks of psychopathology and associated problems.

Advances in the Conceptualization, Assessment, and Treatment of Pediatric Irritability

Pediatric irritability is a functionally impairing transdiagnostic symptom underlying a substantial proportion of child mental health referrals. The past 20 years have witnessed a striking uptick in empirical work focused on pediatric irritability, with increasing recognition of its role across multiple internalizing and externalizing disorders. That said, it has only been in recent years that research has begun to make advances in understanding the natural course and neurobiological underpinnings of irritability across development; research directly informing effective clinical management of pediatric irritability has been limited. At this critical stage in the study of pediatric irritability, this special series brings together the latest work from leading experts across three interrelated domains: (a) progress in understanding the phenomenology and course of pediatric irritability; (b) advances in the assessment of pediatric irritability; and (c) innovations in the treatment of pediatric irritability. The papers in this special series collectively offer critical steps forward for better understanding pediatric irritability and improving proper assessment, classification, and clinical management.