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Normative Irritability in Youth: Developmental Findings From the Great Smoky Mountains Study

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Objective

The goal of this study is to examine the developmental epidemiology of normative irritability and its tonic and phasic components in a longitudinal community sample of youth.

Method

Eight waves of data from the prospective, community Great Smoky Mountains Study (6,674 assessments of 1,420 participants) were used, covering children in the community 9 to 16 years of age. Youth and 1 parent were interviewed using the Child and Adolescent Psychiatric Assessment to assess tonic (touchy/easily annoyed, irritable mood, angry or resentful) and phasic (temper tantrums or anger outbursts) components of irritability, including frequency, duration, onset, and cross-context variability.

Results

At any given point in childhood/adolescence, 51.4% (standard error [SE] = 1.4) of participants reported phasic irritability, 28.3% (SE = 1.2) reported tonic irritability, and 22.8% (SE = 1.1) reported both. These prevalence levels decreased with age but did not vary by sex. The overlap between tonic and phasic irritability was high (odds ratio = 5.8, 95% CI = 3.3–10.5, p < .0001), with little evidence of tonic occurring without phasic irritability. Both tonic and phasic irritability predicted one another over time, supporting both heterotypic and homotypic continuity. Low levels of either tonic or phasic irritability increased risk for disrupted functioning including service use, school suspensions, parental burden, and emotional symptoms both concurrently and at 1-year follow-up.

Conclusion

Irritability is relatively common, decreases with age but does not vary by sex, and at almost any level is associated with increased risk of disrupted functioning. Its relative components frequently overlap, although irritable outbursts are more common than irritable mood. Irritability appears to be a high-priority transdiagnostic marker for screening children in need of clinical attention.

Section snippets

Participants

The Great Smoky Mountains Study is a longitudinal, representative study of children in 11 predominantly rural counties of North Carolina.25 Three cohorts of children, ages 9, 11, and 13 years, were recruited from a pool of some 12,000 children using a 2-stage sampling design, resulting in at total of 1,420 participants (49% female).25 American Indians were oversampled to constitute 25% of the sample, and African Americans comprised 7%. Annual assessments were completed in the 1,420 children

Prevalence of Irritability

At any given point in childhood/adolescence, 51.4% (standard error [SE] = 1.4) of participants reported phasic irritability, 28.3% (SE = 1.2) reported tonic irritability, 56.9% (SE = 1.3) reported either, and 22.8% (SE = 1.1) reported both. Figures 1A to 1D show the 3-month rates of any phasic irritability, tonic irritability, either or both, by age and sex. Rates of both types of irritability decreased significantly from middle childhood to adolescence but did not differ by sex. There was no

Discussion

Despite its ubiquity, little is known about how irritability and its components manifest in the community. Irritability is symptom of oppositional defiant disorder, disruptive mood dysregulation disorder, posttraumatic stress disorder, generalized anxiety disorder, and major depressive episodes, manic episodes, and associated features of many other disorders. This prospective, longitudinal study found that irritability is relatively common, decreases with age but does not vary by sex, and at

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    An interview with the author is available by podcast at www.jaacap.org or by scanning the QR code to the right.

    The work presented here was supported by the National Institute of Mental Health (MH63970, MH63671, MH48085, MH094605), the National Institute on Drug Abuse (DA/MH11301), NARSAD (Early Career Award to W.E.C.), and the William T. Grant Foundation.

    Disclosure: Dr. Copeland has received research support from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Alliance for Research on Schizophrenia and Depression. Dr. Brotman has received research support from the National Institute of Mental Health. Dr. Costello has received research support from the National Institute of Mental Health and the National Institute on Drug Abuse. She was co-recipient of the 2009 National Alliance for Research on Schizophrenia and Depression Ruane Prize for Outstanding Child and Adolescent Psychiatric Research. She is co-author of the following assessment tools: Child and Adolescent Psychiatric Assessment (CAPA), Young Adult Psychiatric Assessment (YAPA), Child and Adolescent Impact Assessment (CAIA), Child and Adolescent Services Assessment (CASA), and Mood and Feelings Questionnaire (MFQ). No personal income is derived from any of these measures.

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