Emotion regulation as central to psychopathology across childhood and adolescence: a commentary on Nobakht et al. (2023).

An important goal of clinical/developmental research is to identify factors contributing to the onset and maintenance of psychopathology - particularly factors that could be modified through intervention. Large-scale, multi-informant, longitudinal studies provide valuable opportunities for testing such etiological hypotheses, as illustrated by Nobakht et al.'s recent six-wave cohort study spanning ages 4-14. At a within-person level, emotion regulation (ER) deficits consistently predicted oppositional defiant disorder (ODD) symptoms (including both irritability and defiance), whereas victimization did not. These results comport with growing evidence highlighting ER's centrality to ODD and psychopathology more broadly. While the ER findings carry promising implications, caution is warranted in interpreting the results for victimization given that its association with psychopathology is well-documented. More research is needed to test precise questions about within- and between-person processes involving ER, victimization, and psychopathology across development. Pressing research questions include whether, how, and when youths' ER can be modified, and with what effects on clinical outcomes.

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.

Toward greater specificity in the nonspecific: Estimating the prevalence of diagnostic irritability and sleep symptoms in adolescents.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) descriptive criterial approach to diagnosis has been criticized for contributing to comorbidity, heterogeneity within conditions, and nonspecificity across conditions. Much research has examined comorbidity and heterogeneity, but less is known about nonspecificity. Here, we examined two nonspecific symptoms: irritability and sleep disturbance. Both are common, clinically significant, and appear in several DSM disorder criteria sets, but their transdiagnostic prevalence is unknown. Leveraging a nationally representative epidemiological study of adolescents (n = 10,148; ages = 13-18), we first identified all instances where irritability or sleep disturbance appears in DSM-5-TR criteria for bipolar, depressive, anxiety, traumatic stress, or disruptive/impulse-control disorders; then found their DSM-IV equivalents in study variables; and finally estimated their prevalence individually and cumulatively across categories. Weighted lifetime prevalence estimates were 79.5% (95% CI [77.8, 81.2]) for irritability and 60.8% [58.7, 62.9] for sleep disturbance. Associations with age and gender were significant but small. Most youth reported multiple symptoms of irritability (weighted M = 3.04, Mdn = 2) and at least one symptom of sleep disturbance (weighted M = 1.61, Mdn = 1). Both problems were extremely common among individuals with specific disorders but were underestimated by the criteria for those conditions. Results suggest that the high prevalence of DSM-defined irritability and sleep problems may be obfuscated by these symptoms being scattered across diagnostic entities. There is a need for more research on assessing, treating, and understanding problems related to irritability and sleep in their own right, cutting across, rather than confined to, particular diagnoses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

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.

Real-time assessment of positive and negative affective fluctuations and mood lability in a transdiagnostic sample of youth.

BACKGROUND: Emotional lability, defined as rapid and/or intense affect fluctuations, is associated with pediatric psychopathology. Although numerous studies have examined labile mood in clinical groups, few studies have used real-time assessments in a well-characterized transdiagnostic sample, and no prior study has included participants with disruptive mood dysregulation disorder (DMDD). The present study leverages ecological momentary assessment (EMA) to assess emotional lability in a transdiagnostic pediatric sample. METHODS: One hundred thirty participants ages 8-18 with primary diagnoses of DMDD, attention-deficit/hyperactivity disorder (ADHD), an anxiety disorder (ANX), or healthy volunteers completed a previously validated 1-week EMA protocol. Clinicians determined diagnoses based on semi-structured interviews and assessed levels of functional impairment. Participants reported momentary affective states and mood change. Composite scores of fluctuations in positive and negative affect were generated. Affect fluctuations were compared between diagnostic groups and tested for their association with functional impairment. RESULTS: Diagnostic groups differed in levels of negative and positive emotional lability. DMDD patients demonstrated the highest level of labile mood compared with other groups. Emotional lability was associated with global impairment in the whole sample. CONCLUSIONS: Both positive and negative emotional lability is salient in pediatric psychopathology and is associated with functional impairment, particularly in DMDD youth.

Enhancing child mental health in school and community settings: A pilot study of the kids' empowerment program.

Many children experience serious mental health problems that, if left untreated, have long-term consequences for their optimal development. Many more have symptoms that fall below clinical thresholds and remain untreated. Yet there are substantial barriers to receiving help. A newly developed preventive intervention program focused on promoting emotional well-being was provided to children in school and community settings and evaluated to assess its effects on mental health outcomes of children's anxiety and depression. Participants in both intervention and control groups completed standardized measures of mental health in interviews (children) and online (parents) at baseline and approximately 12 weeks later. Intent to treat analyses showed a significant interaction effect for program children high in anxiety at baseline using child report. Similar results were found when using per protocol data (number of sessions attended). No effects were found for the outcome of depression with the intent to treat analyses using either child or parent report. However, children who attended more sessions experienced greater change in parent-rated depression and the interaction of sessions attended and baseline depression significantly predicted change in depression when using both child and parent report. Thus, children with greater internalizing problems appeared to benefit most from the program. These preliminary results suggest that it may be possible to address children's mental health challenges in community and school settings. Implications for future study and program enhancements are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).