The Irritable and Oppositional Dimensions of Oppositional Defiant Disorder: Integral Factors in the Explanation of Affective and Behavioral Psychopathology

Commentary: Optimism for the future of research on disruptive behaviors - an appreciation of good science as illustrated by Nobakht, Steinsbekk & Wichstrom (2023)

This paper by Nobakht, Steinsbekk & Wichstrom (2023) is a model of good science in the study of oppositional defiant disorder and conduct disorder. Their approach illustrates a thoughtful research design, statistical modeling sufficient to empirically evaluate developmental processes, and a full consideration of the theoretical implications of their work. This contrasts with a broad history of research on ODD and CD that far too often has only reified biased assumptions about these phenomena rather than rigorously scrutinizing them. Their demonstration of a unidirectional developmental flow of influence from ODD to interparental aggression, and thence to CD highlights a set of complicated developmental processes involving these disorders and their environment. It expands on evidence of the toll that ODD exerts on parents and provides guidance for more specific intervention. Standards in developmental psychopathology research should include testing bidirectional processes and employing designs that could falsify rather than reify existing beliefs. Examining key mechanisms in such processes will more rapidly generate improvements in assessment and treatment.

Dimensionality of Oppositional Defiant Disorder Symptoms Across Elementary-School Grades

Various models of the dimensionality of behaviors associated with Oppositional Defiant Disorder (ODD) have been proposed or reported. Many of these models describe ODD-related behaviors in either two- or three-factor models. The purpose of the study was to determine which of the models of ODD-related behaviors demonstrated the best fit using teacher report of 15,521 children across eight grade levels and to examine measurement invariance of the model across grades. Confirmatory factor analyses were conducted to determine which of the models demonstrated best fit of teacher-reported ODD-related behaviors across eight grades. A two-factor model from a preliminary analysis of a subset of the current data demonstrated a better model fit than any of the existing six models examined and demonstrated measurement invariance across all grades. Across all of the models, affective and behavioral symptoms loaded onto separate factors, which may be an important consideration to inform future clinical and empirical work.

Oppositional Defiant Disorder in Autism and ADHD

Our study compared oppositional defiant disorder (ODD) in children with autism to ADHD-Combined presentation and ADHD-Inattentive presentation. Mothers of 2,400 children 3-17 years old with autism and/or ADHD completed the Pediatric Behavior Scale. ADHD-Combined was most strongly associated with ODD, with an ODD prevalence of 53% in children with ADHD-Combined only. When autism was added to ADHD-Combined, prevalence increased to 62% and the ODD score increased significantly. Autism+ADHD-Inattentive, Autism Only, and ADHD-Inattentive Only had ODD prevalences of 28%, 24% and 14%. In each diagnostic group, ODD had the same two factors (irritable/angry and oppositional/defiant); demographic differences between children with and without ODD were few; and correlations between ODD and conduct problems were large, correlations with depression were medium, and correlations with anxiety were small. However, ODD scores differed significantly between groups (Autism+ADHD-Combined > ADHD-Combined Only > Autism+ADHD-Inattentive and Autism Only > ADHD-Inattentive Only). The irritable/angry ODD component was greater in Autism+ADHD-Combined than in ADHD-Combined Only, whereas the oppositional/defiant component did not differ between the two groups. Autism was a significant independent risk factor for ODD, particularly the irritable/angry ODD component, but ADHD-Combined was the strongest risk factor. Therefore, the high co-occurrence of ADHD-Combined in autism (80% in our study) largely explains the high prevalence of ODD in autism. ADHD-Combined, autism, and ODD are highly comorbid (55-90%). Clinicians should assess all three disorders in referred children and provide evidence-based interventions to improve current functioning and outcomes for children with these disorders and reduce family and caretaker stress.

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.

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.

The Affective Side of Disruptive Behavior: Toward Better Understanding, Assessment, and Treatment

Historically, much of the progress made in youth mental health research can be classified as focusing on externalizing problems, characterized by disruptive behavior (e.g. aggression, defiance), or internalizing problems, characterized by intense negative affect (e.g. depression, anxiety). Until recently, however, less attention has been given to topics that lie somewhere in between these domains, topics that we collectively refer to as the affective side of disruptive behavior. Like the far side of the moon, the affective side of disruptive behavior captures facets of the phenomenon that may be less obvious or commonly overlooked, but are nonetheless critical to understand. This affective side clarifies socially disruptive aspects of traditionally "externalizing" behavior by elucidating proximal causation via intense negative affect (traditionally "internalizing"). Such problems include irritability, frustration, anger, temper loss, emotional outbursts, and reactive aggression. Given a recent explosion of research in these areas, efforts toward integration are now needed. This special issue was developed to help address this need. Beyond the present introductory article, this collection includes 4 empirical articles on developmental psychopathology topics, 4 empirical articles on applied treatment/assessment topics, 1 evidence base update review article on measurement, and 2 future directions review articles concerning outbursts, mood, dispositions, and youth psychopathology more broadly. By deliberatively investigating the affective side of disruptive behavior, we hope these articles will help bring about better understanding, assessment, and treatment of these challenging problems, for the benefit of youth and families.

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

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.

Future Directions in Youth Irritability Research

Research on irritability in children and adolescents has proliferated over the last 20 years. The evidence shows the clinical and developmental significance of irritable mood and behavior in youth, and it has led to significant changes in mental health classification, diagnosis, and services. At the same time, this research (including our own) has led to relatively little new in terms of practical, empirically based guidance to improve interventions and outcomes. In this article, we briefly summarize some of these developments and current evidence-based practices. We then put forth two key substantive challenges (the "whats") for future research to address: (a) the need for more effective treatments, especially evaluating and adapting evidence-based treatments that are already well-established for problems related to irritability (e.g., cognitive-behavioral therapies for internalizing and externalizing problems); and (b) the need for a better mechanistic understanding of irritability's phenomenology (e.g., phasic vs. tonic irritability, how frustration unfolds) and putative underlying mechanisms (e.g., cognitive control, threat and reward dysfunction). Lastly, we suggest three methodological approaches (the "hows") that may expedite progress in such areas: (a) ecological momentary assessment, (b) digital health applications, and (c) leveraging existing datasets. We hope this article will be useful for students and early-career researchers interested in tackling some of these important questions to better meet the needs of severely irritable youth.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a disruptive behaviour disorder involving an ongoing pattern of angry/irritable mood, argumentative/defiant behaviour and vindictiveness. Onset is typically before 8 years of age, although ODD can be diagnosed in both children and adults. This disorder is associated with substantial social and economic burden, and childhood ODD is one of the most common precursors of other mental health problems that can arise across the lifespan. The population prevalence of ODD is ~3 to 5%. A higher prevalence in males than females has been reported, particularly before adolescence. No single risk factor accounts for ODD. The development of this disorder seems to arise from the interaction of genetic and environmental factors, and mechanisms embedded in social relationships are understood to contribute to its maintenance. The treatment of ODD is often successful, and relatively brief parenting interventions produce large sized treatment effects in early childhood. Accordingly, ODD represents an important focus for research, practice and policy concerning early intervention and prevention in mental health.

Vicious cycle of emotion regulation and ODD symptoms among Chinese school-age children with ODD: a random intercept cross-lagged panel model

A strong link between children's emotion regulation and oppositional defiant disorder (ODD) symptoms has been documented; however, the within-person mechanisms remain unclear. Based on the self-control theory and self-regulation theory, our study investigated the longitudinal, bidirectional relationship between emotion regulation and ODD symptoms in school-age children with ODD using parent- and teacher-reported data, respectively. A total of 256 Chinese elementary school students participated in a three-wave longitudinal study spanning two years. We used the random intercept cross-lagged panel model (RI-CLPM) to investigate the concurrent and longitudinal associations between emotion regulation and ODD symptoms. Results from the RI-CLPMs revealed that ODD symptoms were negatively correlated with emotion regulation and positively correlated with emotion lability/negativity at both the between-person and within-person levels across settings. Additionally, in the school setting, emotion regulation negatively predicted subsequent ODD symptoms but not vice versa, whereas emotion lability/negativity was bidirectionally associated with ODD symptoms over time. The longitudinal associations of ODD symptoms with emotion regulation and lability/negativity were not observed in the home setting. These findings suggest a circular mechanism between children's emotion regulation and ODD symptoms and support the view that emotion regulation, particularly emotion lability/negativity, plays an important role in the development of ODD symptoms.

Editorial: Roads Less Traveled: New Directions for Novel Outcomes in Youth Irritability Research

Road metaphors are ubiquitous in youth mental health. Developmental psychopathology research is described in terms of pathways, trajectories, cascades, and transitions. Children's behavioral concerns are discussed as warning signs and rough spots. Although these metaphors have long been useful abstractions, modern quantitative methods and large-scale longitudinal studies have made it possible to empirically investigate the "roads" traveled by individuals across development. One goal here is to chart the paths most often followed by different subgroups of youth. Another goal involves surveying variables that nudge children toward (or away from) psychopathology and other key outcomes. These 2 goals-finding trajectories and predictors thereof-have important implications for research, intervention, and policy; and some of the most important studies, in our view, accomplish both.

Irritability and Emotional Impulsivity as Core Feature of ADHD and ODD in Children

The categorical approach of diagnosing mental disorders entails the problem of frequently occurring comorbidities, suggesting a more parsimonious structure of psychopathology. In this study, we therefore aim to assess how affective dysregulation (AD) is associated with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in children. To assess AD in children aged 8–12 years (n = 391), we employed the parent version of a newly constructed parent rating scale. Following item reduction, we conducted exploratory and confirmatory factor analyses to establish a factorial structure of AD. One core dimension was identified, comprising irritability and emotional impulsivity, and two smaller dimensions, comprising positive emotionality and exuberance. Subsequently, we examined five different latent factor models – a unidimensional model, a first-order correlated factor model, a second-order correlated factor model, a traditional bifactor model, and a bifactor S-1 model, in which the first-order factor AD-Irritability/Emotional Impulsivity (II) was modeled as the general reference factor. A bifactor S-1 model with the a priori defined general reference domain AD-II provided the best fit to our data and was straightforward to interpret. This model showed excellent model fit and no anomalous factor loadings. This still held true, when comparing it to bifactor S-1 models with ADHD/ODD-related reference factors. Differential correlations with emotion regulation skills and the established Parent Proxy Anger Scale validate the interpretation of the different dimensions. Our results suggest that irritability/emotional impulsivity might be a common core feature of ADHD and ODD.

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.