Developmental pathways from preschool irritability to multifinality in early adolescence: the role of diurnal cortisol

Systematic Review and Meta-Analysis: Early Irritability as a Transdiagnostic Neurodevelopmental Vulnerability to Later Mental Health Problems

OBJECTIVE

Irritability is a transdiagnostic indicator of child and adolescent internalizing and externalizing problems that is measurable from early life. The objective of this systematic review was to determine the strength of the association between irritability measured from 0 to 5 years and later internalizing and externalizing problems, to identify mediators and moderators of these relationships, and to explore whether the strength of the association varied according to irritability operationalization.

METHOD

Relevant studies published in peer-reviewed, English-language journals between the years 2000 and 2021 were sought from EMBASE, PsycINFO, MEDLINE, CINAHL, and ERIC. We synthesized studies that included a measure of irritability within the first 5 years of life and reported associations with later internalizing and/or externalizing problems. Methodological quality was assessed using the JBI-SUMARI Critical Appraisal Checklist.

RESULTS

Of 29,818 identified studies, 98 met inclusion criteria, with a total number of 932,229 participants. Meta-analysis was conducted on 70 studies (n = 831,913). Small, pooled associations were observed between infant irritability (0-12 months) and later internalizing (r = 0.14, 95% CI = 0.09, 0.20) and externalizing symptoms (r = 0.16, 95% CI = 0.11, 0.21) symptoms. For toddler/preschool irritability (13-60 months), small-to-moderate pooled associations were observed for internalizing (r = 0.21, 95% CI = 0.14, 0.28) and externalizing (r = 0.24, 95% CI = 0.18, 0.29) symptoms. These associations were not moderated by the lag between irritability and outcome assessment, although the strength of the associations varied according to irritability operationalization.

CONCLUSION

Early irritability is a consistent transdiagnostic predictor of internalizing and externalizing symptoms in childhood and adolescence. More work is required to understand how to accurately characterize irritability across this developmental period, and to understand mechanisms underlying the relationship between early irritability and later mental health problems.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as living with a disability. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

STUDY PREREGISTRATION INFORMATION

Early irritability as a transdiagnostic neurodevelopmental vulnerability to early onset mental health problems: A systematic review; https://www.crd.york.ac.uk/prospero/; CRD42020214658.

Biological sensitivity to adolescent-parent discrepancies in perceived parental warmth

Introduction

Parenting behaviors are formative to the psychological development of young people; however, parent and adolescent perceptions of parenting are only moderately correlated with each other. Whereas discrepant perceptions may represent a normative process of deindividuation from caregivers in some adolescents, in others a discrepancy might predict psychological maladjustment. The biological sensitivity to context model provides a framework from which individual differences in development can be estimated in adolescents whose perceptions of parenting diverge from those of their parents.

Methods

At baseline we obtained diurnal cortisol samples from US adolescents (M = 13.37 years of age, SD = 1.06) as well as parents' and adolescents' ratings of parental warmth; we obtained adolescent-reported symptoms of psychopathology at baseline and again at follow-up two years later (N = 108, 57.5% female). We estimated waking cortisol, cortisol awakening response, and daytime cortisol slopes using piecewise regression models.

Results

Lower adolescent than parent ratings of parental warmth predicted increased externalizing symptoms at follow-up. Higher waking cortisol and steeper cortisol awakening response and daytime slopes predicted increased internalizing symptoms at follow-up. Further, discrepant ratings of parental warmth interacted with cortisol awakening response and daytime slopes such that greater discrepancies predicted greater increases in externalizing symptoms in adolescents with steeper cortisol slopes.

Conclusions

These findings indicate that steeper changes in cortisol production throughout the day index a greater sensitivity to perceived parental warmth. Lower adolescent than parent ratings of parental warmth may represent dysfunction in the parental relationship rather than a normative process of deindividuation in adolescents with steeper diurnal cortisol slopes.

Excessive hair cortisol concentration as an indicator of psychological disorders in children

Cortisol in hair is a new biomarker assessing long-term hypothalamic-pituitary-adrenal (HPA) axis activity, which is related to emotion regulation. We compare hair cortisol concentrations (HCC), in clinically referred children with disruptive mood dysregulation disorder (DMDD) (n = 19), children with other types of psychological disorders (n = 48), and healthy subjects (n = 36). We also investigate the association between HCC and irritability, age, and sex. Our results show that children with DMDD or other types of psychological disorders have higher HCC than healthy subjects, p < .001, ηp2 = .39. No difference between children with DMDD and those with other types of psychological disorders was found, p = .91, nor an association between HCC and irritability in the clinical sample, p = .32. We found a significant negative correlation between HCC and age in those with DMDD, r = -0.54, p < .05, but not in the normative sample, r = -0.20, p = .25. No differences in HCC between girls and boys were found in the normative sample, p = .49. Children in need of psychological treatment, including those with DMDD, seem to have dysregulated HPA-axis activity over time. Excessive accumulated cortisol concentrations in hair could be an indicator of a psychological disorder in children.

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.

Measuring irritability in young adults: An integrative review of measures and their psychometric properties

WHAT IS KNOWN ON THE SUBJECT?: Irritability is a transdiagnostic psychiatric symptom among different mental health diagnoses, such as depression, anxiety, personality and substance abuse disorders. Despite the prevalence of irritability across various psychiatric disorders, there is a lack of assessment measures developed and validated to specifically assess irritability. Existing evidence suggests that young adults with depression combined with irritability experience higher disease burden compared with depressed peers with low levels of irritability. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This integrative review demonstrates that the Brief Irritability Test (BITe) is a more precise and reliable tool for measuring irritability in young adults, particularly in that it differentiates irritability from related but distinct symptoms such as anger, aggression and hostility. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Utilizing valid and reliable tools to measure irritability could help identify the presence of irritability as a distinct construct, which could lead to the development of tailored/personalized mental health interventions that will adequately address the impact of irritability on functioning. The findings have implications for symptom science, one focus of nursing research that evaluates symptom experiences and their impact on quality of life and functioning. Irritability is consistent with this framework as it has disabling effects on educational, financial and social functioning, as well as vulnerability to psychiatric disorders and health-related quality of life. ABSTRACT: Introduction Irritability is associated with a higher burden of psychiatric symptoms and impairments in young adults' educational, financial and social functioning. Still, it has been measured mainly by subscales within larger tools. Few specific measures have been developed to capture this construct validly and reliably, hindering the differentiation of irritability from similar constructs like anger and aggression. Aim This integrative review was undertaken to identify the irritability measures used in young adults between 2000 and 2021. Method The 5-stage method was proposed by Whittemore and Knafl (Journal of Advanced Nursing, 52, 546, 2005). Results Of 1258 results, 15 articles that included young adults as their participants and measured irritability with a specific tool were identified to be reviewed. Discussion Among the existing tools, the Brief Irritability Test (BITe) is a more precise and specific tool in young adults for measuring irritability and differentiating irritability from similar constructs. Implications for practice The findings have potential implications for better assessment and understanding of irritability in nursing research and practice, leading to the development of nursing interventions tailored to the affected young adult populations and improving the quality of life in these groups.

Does stress predict the development of internalizing symptoms in middle childhood? An examination of additive, mediated, and moderated effects of early family stress, daily interpersonal stress, and physiological stress

Early life stress, daily life experiences, and the stress responsive hypothalamic-pituitary-adrenal (HPA) axis have each been examined as predictors of the development of psychopathology. Rarely have researchers attempted to understand the covariation or interaction among these stress domains using a longitudinal design in the prediction of symptoms of internalizing psychopathology, particularly during childhood. This study examined early family stress, daily interpersonal stress, indicators of diurnal cortisol, and internalizing symptoms in a racially/ethnically and socioeconomically diverse sample of twins (N = 970 children; Mage at outcome = 9.73; 52% female; 23.7% Hispanic/Latino, 58.8% White; 30% below middle class; Lemery-Chalfant et al., 2019). An additive model of stress, a stress mediation model, and a stress sensitization framework model each delineated potential pathways linking stress and internalizing symptoms. Supporting additive pathways, multilevel models showed that all 3 stress indicators uniquely predicted internalizing symptoms. There was a significant indirect path from early family stress to 9 year internalizing symptoms through interpersonal stress, supporting stress mediation. Family stress moderated the association between interpersonal stress and internalizing symptoms, though not in the direction that would support stress sensitization. Child stress, including daily interpersonal stress and HPA axis activity, and internalizing symptoms are prevalent and family stress is a significant precursor to child internalizing symptoms across child development. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Developmental patterning of irritability enhances prediction of psychopathology in preadolescence: Improving RDoC with developmental science

The transdiagnostic importance of irritability in psychopathology has been demonstrated. However, the contribution of developmentally unfolding irritability patterns to specific clinical and neural outcomes remains an important and unanswered question. To address this gap in the literature, irritability patterns of 110 youth from a large, diverse cohort were assessed at preschool age and again at early school age (∼2.5 years later) with a dimensional irritability scale designed to capture the normal:abnormal spectrum. At preadolescence (∼6 years later), clinical outcomes (internalizing/externalizing symptoms) derived from a semistructured clinical interview and neural outcomes (characterized as gray-matter-volume abnormalities) were assessed. For clinical outcomes, preschool-age irritability alone was a transdiagnostic predictor of internalizing and externalizing symptoms at preadolescence. However, in a model including both preschool and early school age, irritability provided greater specificity, suggesting that higher irritability at early school age related to elevated preadolescent externalizing but not internalizing symptoms. In terms of neural outcomes, elevated preschool irritability did not predict preadolescent gray-matter-volume abnormality; however, irritability at early school age demonstrated an interactive effect among regions, with reduced volume in preadolescence emotional regions (e.g., amygdala, medial orbitofrontal cortex) and increased volume in other regions (e.g., cerebellum). These complex patterns highlight the contribution of a developmentally informed approach, the National Institute of Mental Health's Research Domain Criteria (RDoC) approach, to yield transdiagnostic phenotypes and multiple units of analysis. Capturing these individual differences and developmental heterogeneity can provide critical insight into the unfolding of mechanisms underlying emerging psychopathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.

A Transdiagnostic Perspective on Youth Irritability

Irritability is increasingly recognized as a significant clinical problem in youth. It is a criterion for multiple diagnoses and predicts the development of a wide range of disorders. Research on etiopathogenesis suggests that genetic and family environmental factors play a role, as do abnormalities in reward and cognitive control circuitry. However, many of these effects are age dependent. Threat-responsive self-regulatory systems and the degree to which irritability manifests as tonic or phasic influence whether irritable youth exhibit more internalizing versus externalizing outcomes.