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

Efficacy of a synbiotic in the management of adults with Attention-Deficit and Hyperactivity Disorder and/or Borderline Personality Disorder and high levels of irritability: Results from a multicenter, randomized, placebo-controlled, "basket" trial

Irritability worsens prognosis and increases mortality in individuals with Attention-Deficit and Hyperactivity Disorder (ADHD) and/or Borderline Personality Disorder (BPD). However, treatment options are still insufficient. The aim of this randomized, double blind, placebo-controlled study was to investigate the superiority of a synbiotic over placebo in the management of adults with ADHD and/or BPD and high levels of irritability. The study was conducted between February 2019 and October 2020 at three European clinical centers located in Hungary, Spain and Germany. Included were patients aged 18-65 years old diagnosed with ADHD and/or BPD and high levels of irritability (i.e., an Affectivity Reactivity Index (ARI-S) ≥ 5, plus a Clinical Global Impression-Severity Scale (CGI-S) score ≥ 4). Subjects were randomized 1(synbiotic):1(placebo); the agent was administered each day, for 10 consecutive weeks. The primary outcome measure was end-of-treatment response (i.e., a reduction ≥ 30 % in the ARI-S total score compared to baseline, plus a Clinical Global Impression-Improvement (CGI-I) total score of < 3 (very much, or much improved) at week 10). Between-treatment differences in secondary outcomes, as well as safety were also investigated. Of the 231 included participants, 180 (90:90) were randomized and included in the intention-to-treat-analyses. Of these, 117 (65 %) were females, the mean age was 38 years, ADHD was diagnosed in 113 (63 %), BPD in 44 (24 %), both in 23 (13 %). The synbiotic was well tolerated. At week 10, patients allocated to the synbiotic experienced a significantly higher response rate compared to those allocated to placebo (OR: 0.2, 95 % CI:0.1 to 0.7; P = 0.01). These findings suggest that that (add-on) treatment with a synbiotic may be associated with a clinically meaningful improvement in irritability in, at least, a subgroup of adults with ADHD and/or BPD. A superiority of the synbiotic over placebo in the management of emotional dysregulation (-3.6, 95 % CI:-6.8 to -0.3; P = 0.03), emotional symptoms (-0.6, 95 % CI:-1.2 to -0.05; P = 0.03), inattention (-1.8, 95 % CI: -3.2 to -0.4; P = 0.01), functioning (-2.7, 95 % CI: -5.2 to -0.2; P = 0.03) and perceived stress levels (-0.6, 95 % CI: -1.2 to -0.05; P = 0.03) was also suggested. Higher baseline RANK-L protein levels were associated with a significantly lower response rate, but only in the synbiotic group (OR: 0.1, 95 % CI: -4.3 to - 0.3, P = 0.02). In the placebo group, higher IL-17A levels at baseline were significantly associated with a higher improvement in in particular, emotional dysregulation (P = 0.04), opening a door for new (targeted) drug intervention. However, larger prospective studies are warranted to confirm the findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03495375.

Parent and Teacher Ratings of Tonic and Phasic Irritability in a Clinical Sample

Research on tonic (persistently angry or grumpy mood) and phasic (temper tantrums/outbursts) irritability in youth has utilized community samples and information from parents and youth. We examined whether tonic and phasic irritability are empirically distinguishable and have similar correlates using teacher, in addition to parent, reports in a clinical sample of children and adolescents. The sample included youth aged 5-18 evaluated at a university outpatient clinic, with complete information from 2481 parents and 2449 teachers. We conducted confirmatory factor analysis (CFA) using items from several parent- and teacher-report inventories and examined concurrent associations with psychopathology and functioning. The CFA supported a two-factor model consistent with tonic and phasic irritability in both parent- and teacher-reports. Parent-reported tonic irritability was associated with higher rates of depression and anxiety disorders, suicidality, and antidepressant medication use. Teacher-reported tonic irritability was associated with elevated rates of depression and antidepressant use. Both parent- and teacher-reported phasic irritability were linked to higher rates of ADHD combined type, oppositional defiant/conduct disorders, and referral for rages. Parent- and teacher-reported tonic and phasic irritability were all associated with impaired social functioning. Parents and teachers can distinguish tonic and phasic irritability, which are associated with internalizing and externalizing problems, respectively. Findings were generally consistent across informants, and with prior studies using community samples.

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.

Irritability in Youths: A Critical Integrative Review

Irritability, defined as proneness to anger that may impair an individual's functioning, is common in youths. There has been a recent upsurge in relevant research. The authors combine systematic and narrative review approaches to integrate the latest clinical and translational findings and provide suggestions for addressing research gaps. Clinicians and researchers should assess irritability routinely, and specific assessment tools are now available. Informant effects are prominent, are stable, and vary by age and gender. The prevalence of irritability is particularly high among individuals with attention deficit hyperactivity disorder, autism spectrum disorder, and mood and anxiety disorders. Irritability is associated with impairment and suicidality risk independent of co-occurring diagnoses. Developmental trajectories of irritability (which may begin early in life) have been identified and are differentially associated with clinical outcomes. Youth irritability is associated with increased risk of anxiety, depression, behavioral problems, and suicidality later in life. Irritability is moderately heritable, and genetic associations differ based on age and comorbid illnesses. Parent management training is effective for treating psychological problems related to irritability, but its efficacy in treating irritability should be tested rigorously, as should novel mechanism-informed interventions (e.g., those targeting exposure to frustration). Associations between irritability and suicidality and the impact of cultural context are important, underresearched topics. Analyses of large, diverse longitudinal samples that extend into adulthood are needed. Data from both animal and human research indicate that aberrant responses to frustration and threat are central to the pathophysiology of irritability, revealing important translational opportunities.

Evidence Base Update on the Assessment of Irritability, Anger, and Aggression in Youth

OBJECTIVE

Irritability, anger, and aggression have garnered significant attention from youth mental health researchers and clinicians; however, fundamental challenges of conceptualization and measurement persist. This article reviews the evidence base for assessing these transdiagnostic constructs in children and adolescents.

METHOD

We conducted a preregistered systematic review of the evidence behind instruments used to measure irritability, anger, aggression, and related problems in youth. Searches were conducted in PsycINFO and PubMed, identifying 4,664 unique articles. Eligibility criteria focused on self- and proxy-report measures with peer-reviewed psychometric evidence from studies in English with youths ages 3-18. Additional measures were found through ancillary search strategies (e.g. book chapters, review articles, test publishers). Measures were screened and coded by multiple raters with acceptable reliability.

RESULTS

Overall, 68 instruments met criteria for inclusion, with scales covering irritability (n = 15), anger (n = 19), aggression (n = 45), and/or general overt externalizing problems (n = 27). Regarding overall psychometric support, 6 measures (8.8%) were classified as Excellent, 46 (67.6%) were Good, and 16 (23.5%) were Adequate. Descriptive information (e.g. informants, scales, availability, translations) and psychometric properties (e.g. reliability, validity, norms) are summarized.

CONCLUSIONS

Numerous instruments for youth irritability, anger, and aggression exist with varying degrees of empirical support for specific applications. Although some measures were especially strong, none had uniformly excellent properties across all dimensions, signaling the need for further research in particular areas. Findings promote conceptual clarity while also producing a well-characterized toolkit for researchers and clinicians addressing transdiagnostic problems affecting youth.

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.

Changes in Internalizing Symptoms During the COVID-19 Pandemic in a Transdiagnostic Sample of Youth: Exploring Mediators and Predictors

The COVID-19 pandemic is a chronically stressful event, particularly for youth. Here, we examine (i) changes in mood and anxiety symtpoms, (ii) pandemic-related stress as a mediator of change in symptoms, and (ii) threat processing biases as a predictor of increased anxiety during the pandemic. A clinically well-characterized sample of 81 youth ages 8-18 years (M = 13.8 years, SD = 2.65; 40.7% female) including youth with affective and/or behavioral psychiatric diagnoses and youth without psychopathology completed pre- and during pandemic assessments of anxiety and depression and COVID-related stress. Forty-six youth also completed a threat processing fMRI task pre-pandemic. Anxiety and depression significantly increased during the pandemic (all ps < 0.05). Significant symptom change was partially mediated by pandemic stress and worries. Increased prefrontal activity in response to neutral faces pre-pandemic was associated with more intense parent-reported anxiety during the pandemic (all Fs(1.95,81.86) > 14.44, ps < 0.001). The present work extends existing knowledge on the mediating role of psychological stress on symptoms of anxiety and depression in youth.

A pragmatic, clinically optimized approach to characterizing adolescent irritability: Validation of parent- and adolescent reports on the Multidimensional Assessment Profile Scales-Temper Loss Scale

OBJECTIVES

Heightened irritability in adolescence is an impairing symptom that can lead to negative outcomes in adulthood, but effective screening tools are lacking. This study aimed to derive clinically-optimized cutoff scores using the Multidimensional Assessment Profile Scales-Temper Loss (MAPS-TL) to pragmatically identify adolescents with impairing irritability.

METHODS

A diverse sample of 79 adolescents and their parents completed the MAPS-TL-Youth version. Stepwise logistic regression analyses were used to determine the items associated with impairment, and receiver operator characteristic (ROC) analyses were conducted to derive optimal cutoff scores.

RESULTS

Three parent-report items (become frustrated easily, angry/irritable/grouchy throughout the day, difficulty calming down when angry) and two youth-report items (hit/shove/kick when lost temper, difficulty calming down when angry) were strongly associated with impairment. Optimal cutoff scores garnered very good sensitivity (91%, 73%) and specificity (77%, 75%) for the parent- and youth-report versions respectively. Scores above these cutoffs were associated with increased internalizing and externalizing problems and lower overall quality of life.

CONCLUSIONS

The MAPS-TL clinically optimized irritability scores show preliminary validity for implementation in practical settings to efficiently identify adolescents who need additional evaluation and/or intervention. Further research is important to validate these cutoff scores with larger population-based samples and real-world settings.

Irritability: A concept analysis

Irritability is a term used to describe feelings of anger, annoyance and impatience, and is commonly experienced by individuals in daily life. However, there are diverse conceptualizations of irritability in public and clinical research, which often result in confusing irritability with anger and other overlapping concepts. This, in turn, leads to a lack of conceptual clarity. Accordingly, the purpose of this concept analysis was to explore the irritability concept, including its definitions, defining characteristics, antecedents, consequences and empirical referents. The findings showed that irritability is predominantly conceptualized as a psychophysiological concept in the literature. We demonstrated that irritability can be differentiated from overlapping concepts like anger by qualities, such as 'unpredictability and lowered emotion control', 'lowered threshold for negative emotional stimuli', 'being manifested in response to frustrative situations or physiological needs' and 'experience of disproportionate and unjustified emotional irritation'. Importantly, severe irritability prospectively predicts psychiatric disorders and greater impairments in health, financial, educational and social functioning in individuals. Taken together, our analysis showed that one should take into account the context, duration, intensity and importantly outcomes, when assessing irritability in an individual. Considering these findings and the presence of irritability in nursing practice, it is crucial for nurses to recognize and successfully identify this concept in the nursing care they provide within the diverse settings and patient populations.

Network analysis of ecological momentary assessment identifies frustration as a central node in irritability

BACKGROUND

Irritability presents transdiagnostically, commonly occurring with anxiety and other mood symptoms. However, little is known about the temporal and dynamic interplay among irritability-related clinical phenomena. Using a novel network analytic approach with smartphone-based ecological momentary assessment (EMA), we examined how irritability and other anxiety and mood symptoms were connected.

METHODS

Sample included 152 youth ages 8-18 years (M ± SD = 12.28 ± 2.53; 69.74% male; 65.79% White) across several diagnostic groups enriched for irritability including disruptive mood dysregulation disorder (n = 34), oppositional defiant disorder (n = 9), attention-deficit/hyperactivity disorder (n = 47), anxiety disorder (n = 29), and healthy comparisons (n = 33). Participants completed EMA on irritability-related constructs and other mood and anxiety symptoms three times a day for 7 days. EMA probed symptoms on two timescales: "since the last prompt" (between-prompt) versus "at the time of the prompt" (momentary). Irritability was also assessed using parent-, child- and clinician-reports (Affective Reactivity Index; ARI), following EMA. Multilevel vector autoregressive (mlVAR) models estimated a temporal, a contemporaneous within-subject and a between-subject network of symptoms, separately for between-prompt and momentary symptoms.

RESULTS

For between-prompt symptoms, frustration emerged as the most central node in both within- and between-subject networks and predicted more mood changes at the next timepoint in the temporal network. For momentary symptoms, sadness and anger emerged as the most central node in the within- and between-subject network, respectively. While anger was positively related to sadness within individuals and measurement occasions, anger was more broadly positively related to sadness, mood lability, and worry between/across individuals. Finally, mean levels, not variability, of EMA-indexed irritability were strongly related to ARI scores.

CONCLUSIONS

This study advances current understanding of symptom-level and temporal dynamics of irritability. Results suggest frustration as a potential clinically relevant treatment target. Future experimental work and clinical trials that systematically manipulate irritability-related features (e.g. frustration, unfairness) will elucidate the causal relations among clinical variables.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Editorial: The Boundaries of Irritability and Implications for Measurement

Irritability is a defining feature or symptom in at least 15 DSM-5 disorders,¹ and this does not even account for many more disorders that commonly co-occur with irritability. However, just as the transdiagnostic nature of irritability supports its unequivocal importance in child mental health, it also contributes to criticisms that it is "ubiquitous."² How to conceptualize the role of irritability in psychopathology rests on our ability to define it and its boundaries. Unfortunately, there is a lack of consensus on the definition of irritability. In fact, how to disentangle irritability's mood and behavioral components has been described as one of the biggest challenges related to irritability research.³ This editorial is a commentary on Zik et al.'s⁴ study, which takes an emprical approach to determine the overlap between questionnaire measures of irritability, anger, and aggression, thereby informing our conceptualization of irritabiltiy and focusing attention on critical measurement issues such as the impact of informant.

Changes in executive function in pediatric brain tumor survivors

OBJECTIVE

Pediatric oncology survivors are at risk for executive function (EF) and working memory (WM) deficits, which can be measured via performance-based measures or rating scales. Previous studies have shown these measurement methods to be weakly correlated. This study aimed to describe parent-rated EF and performance-based WM (PBWM) in pediatric brain tumor (BT) survivors, examine change in EF and PBWM across time, and investigate the relationship between parent-rated WM and PBWM.

METHOD

The sample included 56 patients diagnosed with a BT in childhood (M_age  = 6.94 years; SD = 4.05) seen twice for clinical neuropsychological evaluation. PBWM was examined via the auditory WM scale from a Wechsler intelligence measure or Differential Ability Scales-II. Parents completed the Behavior Rating Inventory of Executive Function (BRIEF)/BRIEF-P/BRIEF-2 as a measure of global EF (Global Executive Composite [GEC]), metacognitive skills (Metacognitive Index/Cognitive Regulation Index [MI/CRI]), behavioral regulation (Behavior Regulation Index [BRI]), and emotional regulation (Emotion Regulation Index [ERI]).

RESULTS

GEC, MI/CRI, and ERI at Time 1 were significantly above the mean (p < .01); BRI and PBWM did not differ from the normative mean. All measures were significantly higher than the normative mean at Time 2 (p < .05). PBWM was both clinically and statistically elevated (p < .001). There was a significant change across time in PBWM (p < .05), but not GEC, MI/CRI, ERI, or BRI. PBWM was weakly correlated with the BRIEF WM subscale at Time 1 and Time 2 (all p > .05).

CONCLUSIONS

Multiple measures of EF should be considered when providing diagnoses and recommendations for pediatric BT survivors. Furthermore, given declines across time, findings document need for continued monitoring and reassessment of survivors as they get further out from treatment.