Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention

doi:10.1016/j.beth.2019.05.006

Behavior Therapy

Volume 51, Issue 2, March 2020, Pages 238-252

https://doi.org/10.1016/j.beth.2019.05.006 Get rights and content

Highlights

•
This three-wave longitudinal study explored mechanisms of irritability in children.
•
Irritability predicted multiple internalizing and externalizing problems over 6 and 12 months.
•
Irritability was linked to intolerance of uncertainty, emotion coping, and rumination.
•
Difficulties with emotions and uncertainty mediated paths from irritability to later problems.
•
Treatment should consider children’s management of uncertainty and unpleasant emotions.

Abstract

Severe irritability is a common and clinically important problem longitudinally associated with internalizing and externalizing problems in children. To better understand these mechanisms and to inform treatment research, we tested cognitive-behavioral processes as candidate mediators in the paths from irritability to later problems. Methods: A school sample (N = 238, 48% female, ages 8–10) was assessed at ~6-month intervals in fall (T1) and spring (T2) of third to fourth grade, and again the following fall (T3). Measures assessed irritability (T1/predictor); anger and sadness coping, intolerance of uncertainty, and rumination; (T1–T2/mediators); and anxiety, depressive symptoms, reactive aggression, and oppositionality (T1–T3/outcomes). Focused cross-lagged panel models, controlling for gender and grade, were specified to examine full (X_T1 ➔ M_T2 ➔ Y_T3) and half (X_T1 ➔ M_T2; M_T1 ➔ Y_T2) longitudinal mediation. Across one or more intervals, irritability predicted higher depressive symptoms, anxiety, reactive aggression, oppositionality, intolerance of uncertainty, and poor emotion coping. From T1 irritability to T2/T3 outcomes, mediation was found for poor sadness coping leading to reactive aggression and oppositionality; poor anger coping to anxiety, depressive symptoms, and oppositionality; and intolerance of uncertainty to anxiety. Results offer further evidence for internalizing and externalizing outcomes of youth irritability and new evidence suggesting underlying mechanisms. Irritability may confer risk for externalizing problems via poor sadness/anger coping, and for internalizing problems via poor anger coping and intolerance of uncertainty. Theoretical models and psychosocial treatment should consider addressing regulation of various unpleasant emotions as well as psychological flexibility and tolerating uncertainty.

Section snippets

Exploring Candidate Mediators

The logic of the present study is consistent with several recent recommendations, including those for advancing evidence-based practice in youth mental health (e.g., Ng and Weisz, 2016, Roberts et al., 2017) and for advancing the clinical science of irritability from a transdiagnostic perspective (Meyers et al., 2017, Zachary and Jones, 2019). In particular, we adopt an experimental therapeutics framework (Insel & Gogtay, 2014) from a youth psychotherapy perspective. Experimental therapeutics

The Present Study

Based on this literature, and to advance the clinical science of severe irritability, the present study investigates three putative mechanisms (emotion [anger, sadness] coping, intolerance of uncertainty, and rumination) as possible mediators in the path from irritability to subsequent emotional and behavioral outcomes (anxiety, depressive symptoms, reactive aggression, and oppositionality) among school-age children. We focus on this developmental period for several reasons: (a) to inform

participants and procedures

Participants were a school-based sample of 238 children (51.7% male; M_age = 8.9 years, range 8–10), who at baseline were enrolled in third grade (n = 106) or fourth grade (n = 132). Children were recruited and assessed on three occasions separated by ~ 6-month intervals in consecutive fall (T1), spring (T2), and fall (T3) semesters. Self- and teacher-report rating scale measures were collected during the last month of each semester. Self-report measures were collected in approximately 30-minute

Results

Table 1 presents descriptive statistics and correlations for variables of interest. Irritability showed zero-order correlations with all mediator and outcome variables across all time points, and cross-sectional patterns of correlations among study variables were similar at T1, T2, and T3. Regarding hypothesized associations, irritability was cross-sectionally most strongly correlated with anger coping, intolerance of uncertainty, and rumination (rs = .55–.56), with a weaker correlation for

Discussion

Previous work has shown that youth irritability predicts internalizing and externalizing problems—but little is known about how this risk is conferred or how psychosocial treatments might intervene. The present study sought to address this gap by exploring candidate psychological mediators (emotion coping, intolerance of uncertainty, rumination) in the paths from irritability to internalizing (anxiety, depressive symptoms) and externalizing (reactive aggression, oppositionality) problems in

Conclusions

The present study provides further evidence for multiple internalizing and externalizing outcomes of youth irritability, and new evidence regarding the mechanisms that may mediate these outcomes. Specifically, irritability may confer risk for (a) externalizing problems via poor sadness and anger coping, (b) internalizing problems via poor anger coping, and (c) anxiety symptoms via intolerance of uncertainty. Emotion coping, intolerance of uncertainty, and rumination may all be relevant to the

References (64)

A. Aldao et al.
Emotion-regulation strategies across psychopathology: A meta-analytic review
Clinical Psychology Review
(2010)
J.D. Burke et al.
Dimensions of oppositional defiant disorder as predictors of depression and conduct disorder in preadolescent girls
Journal of the American Academy of Child and Adolescent Psychiatry
(2010)
R.N. Carleton et al.
Fearing the unknown: A short version of the Intolerance of Uncertainty Scale
Journal of Anxiety Disorders
(2007)
S.C. Evans et al.
Irritability in child and adolescent psychopathology: An integrative review for ICD-11
Clinical Psychology Review
(2017)
M. Freeston et al.
Why do people worry?
Personality and Individual Differences
(1994)
J.L. Hamilton et al.
Trait affect, emotion regulation, and the generation of negative and positive interpersonal events
Behavior Therapy
(2017)
K.E. Lewandowski et al.
Development of novel behavioral interventions in an experimental therapeutics world: Challenges, and directions for the future
Schizophrenia Research
(2018)
G.S. Malhi et al.
Irritability and internalizing symptoms: Modeling the mediating role of emotion regulation
Journal of Affective Disorders
(2017)
D.P. McKenzie et al.
Predicting future depression in adolescents using the Short Mood and Feelings Questionnaire: A two-nation study
Journal of Affective Disorders
(2011)
E. Meyers et al.
Disruptive mood dysregulation disorder (DMDD): An RDoC perspective
Journal of Affective Disorders
(2017)

W.E. Pelham et al.

Teacher ratings of DSM-R-III symptoms for the disruptive behavior disorders

Journal of the American Academy of Child and Adolescent Psychiatry

(1992)

F. Perepletchikova et al.

Randomized clinical trial of dialectical behavior therapy for preadolescent children with disruptive mood dysregulation disorder: Feasibility and outcomes

Journal of the American Academy of Child and Adolescent Psychiatry

(2017)

M.J. Toohey et al.

Defining and measuring irritability: Construct clarification and differentiation

Clinical Psychology Review

(2017)

P. Vidal-Ribas et al.

The status of irritability in psychiatry: A conceptual and quantitative review

Journal of the American Academy of Child and Adolescent Psychiatry

(2016)

J.G. Waxmonsky et al.

A randomized clinical trial of an integrative group therapy for children with severe mood dysregulation

Journal of the American Academy of Child and Adolescent Psychiatry

(2016)

J.R. Abela et al.

Responses to depression in children: Reconceptualizing the relation among response styles

Journal of Abnormal Child Psychology

(2007)

A. Angold et al.

Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents

International Journal of Methods in Psychiatric Research

(1995)

C. Boulter et al.

Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders

Journal of Autism and Developmental Disorders

(2014)

M.A. Brotman et al.

Irritability in children and adolescents

Annual Review of Clinical Psychology

(2017)

M.A. Brotman et al.

Irritability in youths: A translational model

American Journal of Psychiatry

(2017)

G.A. Carlson et al.

Commentary: Frying pan to fire? Commentary on Stringaris et al. (2018)

Journal of Child Psychology and Psychiatry

(2018)

A. Caspi et al.

The p factor: One general psychopathology factor in the structure of psychiatric disorders?

Clinical Psychological Science

(2014)

D.A. Cole et al.

Testing mediational models with longitudinal data: Questions and tips in the use of structural equation modeling

Journal of Abnormal Psychology

(2003)

B.E. Compas et al.

Coping, emotion regulation, and psychopathology in childhood and adolescence: A meta-analysis and narrative review

Psychological Bulletin

(2017)

N.R. Crick et al.

A review and reformulation of social information-processing mechanisms in children’s social adjustment

Psychological Bulletin

(1994)

O.J. Derella et al.

CBT-enhanced emotion regulation as a mechanism of improvement for childhood irritability

Journal of Clinical Child and Adolescent Psychology

(2019)

K.A. Dodge et al.

Social-information processing factors in reactive and proactive aggression in children’s peer groups

Journal of Personality and Social Psychology

(1987)

M.J. Dugas et al.

The role of intolerance of uncertainty in etiology and maintenance

S.C. Evans et al.

Teacher-reported irritable and defiant dimensions of oppositional defiant disorder: Social, behavioral, and academic correlates

School Mental Health

(2016)

S.C. Evans et al.

The Research Network for Youth Mental Health

Effects of standard and modular psychotherapies in the treatment of youth with severe irritability

(2019)

K.C. Fernandez et al.

Emotion regulation: A transdiagnostic perspective on a new RDoC domain

Cognitive Therapy and Research

(2016)

P.J. Fite et al.

Proactive and reactive aggression

Cited by (16)

Irritability and mental health profiles among children and adolescents: A result of latent profile analysis
2022, Journal of Affective Disorders
Citation Excerpt :
Indeed, a meta-analysis (Vidal-Ribas et al., 2016) reported that irritability is associated with odds ratios of 1.7 for subsequent anxiety problems, 1.8 for depression, and 2.6 for ODD. In addition, several longitudinal studies (Evans et al., 2020; Humphreys et al., 2019) have indicated that irritability in children and adolescents predicts later internalizing and externalizing problems. Thus, irritability is not only a transdiagnostic symptom for anxiety, depression, and oppositionality, but also a pivotal symptom for explaining the development of these symptoms in children and adolescents.
Irritability is a transdiagnostic symptom that accompanies both internalizing and externalizing problems. However, there has been a scarcity of research concerning the relationships between irritability and mental health profiles among children and adolescents.
This study aimed to identify latent profiles in children and adolescents using anxiety, depression, oppositionality, and irritability. In addition, the profiles were further examined in their relationships with mental health symptoms.
The study analyzed data from 1867 children and adolescents aged 6–15 years from the COVID-19 Online-Survey for Children and Adolescents in Japan (J-COSCA). Parent-reported questionnaires were used in this study.
A latent profile analysis detected five latent profiles. High oppositionality characterized the first profile (“oppositional”: n = 405, 22%). High levels of depression and other less pronounced symptoms characterized the second profile (“depressed”: n = 276, 15%). The third profile (“average”: n = 602, 33%) presented average symptoms of anxiety, depression and oppositionality and low irritability. The fourth profile (“well-adjusted”: n = 235, 13%) presented low values for all the applicable symptoms. The last profile (“comorbid”: n = 308, 17%) exhibited high values for all the symptoms and the highest level of irritability of the five profiles.
We analyzed the data from a community sample alone after capturing it using parent-reported questionnaires.
This study revealed that the five profiles (oppositional, depressed, average, well-adjusted, and comorbid) were identified, and children and adolescents in the comorbid profiles had high irritability as well as high anxiety, depression, and oppositionality.
Outcome Findings and Issues in Psychotherapy With Children and Adolescents: Externalizing Disorders
2022, Comprehensive Clinical Psychology, Second Edition
Youth with externalizing disorders are a heterogeneous group with varied, severe, and persistent emotional, social, and behavioral challenges. Effective psychotherapy to prevent and reduce the morbidity and societal costs associated with externalizing disorders is imperative. Psychotherapies for youth with externalizing disorders include those completed with the youth, their parents, the family, and the broader family and community systems. This article first reviews the etiology and conceptual frameworks that underpin psychotherapies for youth with externalizing disorders. Next, the evidence-base and components of widely used psychotherapies are discussed along with the factors that promote or limit psychotherapeutic engagement and effectiveness. Although a number of empirically supported psychotherapies exist, these are only moderately effective for reducing externalizing behavior, so consideration is given to future innovation that may be necessary to improve effectiveness and enhance outcomes.
Irritability in Children and Adolescents With OCD
2021, Behavior Therapy
Citation Excerpt :
This approach may also better estimate the prevalence of elevated irritability in youths with OCD; this study estimated that 22% experience “elevated” irritability, which was lower than expected based on prior studies (Krebs et al., 2013; Shimshoni et al., 2020; Storch et al., 2012). It was surprising that beliefs related to a responsibility to prevent harm, inflated threat perceptions, and intolerance of uncertainty/perfectionism were not associated with irritability given research linking irritability with sensitive threat responding in lab-based paradigms (Salum et al., 2017) and recent survey research finding a link between irritability and intolerance of uncertainty (Evans, Blossom, et al., 2020; Evans, Weisz, et al., 2020). Future work may seek to develop questionnaires that assess beliefs and behaviors that are more reliably associated with clinical presentations of irritability in addition to lab-based behavioral investigations, adding to an understanding of irritability along multiple levels of analysis.
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.
Measurement and correlates of irritability in clinically referred youth: Further examination of the Affective Reactivity Index
2021, Journal of Affective Disorders
Citation Excerpt :
However, an independent investigation of the original measure's psychometric properties is still needed. Further, the associations between irritability and psychopathology (e.g., internalizing, externalizing, and emotion regulation problems) underscores the need for research investigating irritability's characteristics in general youth mental health settings (Evans, Blossom, et al., 2020; Humphreys et al., 2019; Stringaris et al., 2018). Indeed, previous ARI studies have mostly been conducted with community populations, in a language other than English, and/or with only one informant (e.g., youth-report only).
Background: Research on youth irritability has proliferated in recent years, largely facilitated by items from existing measures and by key new instruments like the Affective Reactivity Index (ARI). The present study extends this literature by investigating the psychometric properties of the parent- and youth-report ARI and the correlates of irritability in an independent, clinically referred sample.
Method: Baseline assessment data were collected from 237 youths (ages 3-18; 36% female) and their parents, seen for outpatient therapy and/or assessment. We examined the ARI in terms of (1) its item, scale, and factor properties; (2) convergent/discriminant validity with internalizing, externalizing, and emotion regulation problems; (3) specificity of associations with reactive aggression, anger, dysregulation, and coping; and (4) robustness of associations after controlling for demographic variables (e.g., age, gender).
Results: The ARI's internal consistency and unidimensional factor structure were acceptable or better, with some variation across items and informants. Irritability, as measured by parent- and youth-report, was associated with variables in the externalizing (inattention, hyperactivity, executive dysfunction, aggression), internalizing (anxiety, depression, suicidality), and emotion regulation domains. Associations with reactive aggression, anger, dysregulation, and coping problems were especially pronounced. Irritability's links with internalizing and externalizing problems remained robust after controlling for demographic covariates.
Limitations: The sample was limited in diversity and moderate in size.
Conclusions: Findings support the reliability and validity of the ARI for assessing parent- and youth-rated irritability among clinically referred youth. Future research is needed to understand variations in irritability's manifestations, measurement, and correlates across demographic groups.
Joining the pieces in childhood irritability: Distinct typologies predict conduct, depressive, and anxiety symptoms
2021, Behaviour Research and Therapy
Citation Excerpt :
In turn, this profile scored significantly higher on conduct disorder and depressive symptoms relative to either Low Irritability/High Positive Wellbeing Characteristics youth or Moderate Irritability/Low Behavioural Control youth. This profile echoes previous variable-centered research suggesting that irritability in children is related to reduced regulatory capacities (e.g., Evans, Blossom, & Fite, 2019; Lengua, 2003). This problematic profile likewise highlights that youth with high irritability tend to have comorbid social functioning problems, including low prosocial behaviours and high peer problems, which is again consistent with some variable-centered research (Beauchaine & Cicchetti, 2019; Brotman, Kircanski, & Leibenluft, 2017; Winsler et al., 1997).
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
2020, Behavior Therapy
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.

View all citing articles on Scopus

^☆: The authors thank the students, teachers, staff, and administrators who participated in this research. We gratefully acknowledge support from the American Psychological Foundation (Elizabeth Munsterberg Koppitz Child Psychology Graduate Fellowship to SCE), University of Kansas (Lillian Jacobey Baur Early Childhood Fellowship to SCE, Doctoral Student Research Fund Awards to SCE and JBB, Pioneers Classes Dissertation Research Award to SCE, Faculty Research Fund Award to PJF), and AIM for Mental Health (AIM Fellowship to SCE).

View full text

Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention☆

Highlights

Abstract

Section snippets

Exploring Candidate Mediators

The Present Study

participants and procedures

Results

Discussion

Conclusions

Clinical Psychology Review

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Anxiety Disorders

Clinical Psychology Review

Personality and Individual Differences

Behavior Therapy

Schizophrenia Research

Journal of Affective Disorders

Journal of Affective Disorders

Journal of Affective Disorders

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Clinical Psychology Review

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Responses to depression in children: Reconceptualizing the relation among response styles

Journal of Abnormal Child Psychology

Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents

International Journal of Methods in Psychiatric Research

Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders

Journal of Autism and Developmental Disorders

Irritability in children and adolescents

Annual Review of Clinical Psychology

Irritability in youths: A translational model

American Journal of Psychiatry

Commentary: Frying pan to fire? Commentary on Stringaris et al. (2018)

Journal of Child Psychology and Psychiatry

The p factor: One general psychopathology factor in the structure of psychiatric disorders?

Clinical Psychological Science

Testing mediational models with longitudinal data: Questions and tips in the use of structural equation modeling

Journal of Abnormal Psychology

Coping, emotion regulation, and psychopathology in childhood and adolescence: A meta-analysis and narrative review

Psychological Bulletin

A review and reformulation of social information-processing mechanisms in children’s social adjustment

Psychological Bulletin

CBT-enhanced emotion regulation as a mechanism of improvement for childhood irritability

Journal of Clinical Child and Adolescent Psychology

Social-information processing factors in reactive and proactive aggression in children’s peer groups

Journal of Personality and Social Psychology

The role of intolerance of uncertainty in etiology and maintenance

Teacher-reported irritable and defiant dimensions of oppositional defiant disorder: Social, behavioral, and academic correlates

School Mental Health

The Research Network for Youth Mental Health

Effects of standard and modular psychotherapies in the treatment of youth with severe irritability

Emotion regulation: A transdiagnostic perspective on a new RDoC domain

Cognitive Therapy and Research

Proactive and reactive aggression