Deciphering Irritability in Children: Causes and Links to Comorbidities
Irritability is to mental health providers what fevers are to pediatricians: a core symptom of many disparate conditions. This guide to irritability offers an overview of those conditions and treatment approaches for each.
What Is Irritability?
Grouchy. Moody. Easily frustrated and annoyed. Short-tempered.
All youth experience these symptoms of irritability — an emotional state characterized by proneness to anger — from time to time. But irritability, especially if it’s persistent, intense, and impacts functioning, could indicate something more than typical adolescence development. From attention deficit hyperactivity disorder (ADHD) to disruptive mood dysregulation disorder (DMDD) to bipolar disorder (BPD), irritability is a symptom and trait shared by several psychiatric conditions.
Accurately tracing clinically significant irritability to the right condition(s) — a process requiring careful differential diagnosis — is Step One to managing it. But regardless of diagnosis, all children and teens experiencing intense irritability can benefit from building emotional and behavioral regulation skills. Emerging research on irritability in youth provides valuable ideas and directions for interventions.
What Causes Irritability in Children?
Irritability (at normative levels) may be caused and triggered by stress, insufficient sleep, and/or mood swings during puberty. Irritability rises to clinically significant levels when it is persistent, severe, and/or inconsistent with age and development. Serious irritability is thought to affect up to 5% of people.1 Irritability is also among the most common reasons for youth referral to psychiatric care.2 Researchers believe that deficits in certain brain processes explain pathological irritability.
Irritability and Frustrative Non-Reward
Irritability occurs when we are unable to attain the goal or reward we want — a concept known as frustrative non-reward. Healthy brains learn when to expect rewards and how to adjust behaviors to make attaining a reward or goal (and avoiding punishment) more likely. Researchers hypothesize that irritable youth exhibit deficits in these processes, which make the experience of frustrative non-reward more likely, and the task of working around it more difficult.2
Irritability and Threat-Processing Deficits
Anger and aggression are normal responses to a threat. But compared to non-irritable children, irritable youth may misinterpret neutral or low-level stimuli as highly threatening — a deficit in threat-processing that could give way to temper outbursts and aggression.2 Researchers theorize that both reward- and threat-processing deficits interact and intensify irritability in children.
Tonic Irritability vs. Phasic Irritability
Understanding irritability based on its persistence is especially useful for diagnosis. A patient exhibits tonic (chronic) irritability when anger, grouchiness, and annoyance are persistent and part of their baseline mood. This type of irritability predicts subsequent internalizing disorders, like depression and anxiety.3
Temper outbursts and aggression, on the other hand, characterize phasic (episodic) irritability. This dimension of irritability predicts subsequent externalizing disorders like ADHD and ODD, to name a few.3
Irritability Across Conditions: Distinguishing Features
As a non-specific, transdiagnostic symptom, irritability is to mental health providers what fevers are to pediatricians. Just as a fever is a core symptom of numerous illnesses and infections, irritability is a core symptom of many mental conditions.
We can narrow down irritability to its likely cause by looking at the diagnostic criteria and associated features of the conditions wherein irritability factors prominently.
Chronic, severe irritability is at the core of DMDD, which causes children to have frequent and extreme outbursts, often in response to frustration, that are out of proportion to the situation or trigger. Outbursts can be in the form of verbal rage or physical aggression.
DMDD first appeared in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in response to concerns that a subset of chronically irritable children was being incorrectly diagnosed and/or treated for pediatric bipolar disorder.
- Temper outbursts must occur, on average, three or more times per week in at least two settings, and for over a year, to merit a DMDD diagnosis.
- Between outbursts, children with DMDD must display a persistently irritable or angry mood in at least two settings. As such, tonic and phasic irritability, at the highest levels, characterize DMDD.
DMDD can co-occur with ADHD, conduct disorder, and major depressive disorder (MDD).
Age of Onset
DMDD cannot be diagnosed before age 6, but symptoms should be present by age 10.
- DMDD cannot co-occur with oppositional defiant disorder (ODD), intermittent explosive disorder (IED), or bipolar disorder. If a child meets criteria for ODD and DMDD, they should only get the latter diagnosis.
- DMDD cannot be diagnosed if a child has experienced a manic or hypomanic episode.
A pattern of angry/irritable mood, argumentative/defiant behaviors, or vindictiveness define ODD. The following three symptoms make up the angry/irritable mood category of ODD:
- often loses temper
- is often touchy or easily annoyed
- is often angry and resentful
Additional Mood Characteristics
- Given ODD’s diagnostic criteria, whereby children need at least four symptoms from any of these categories to merit diagnosis, it’s possible that some patients may fall under the irritable/angry subtype of ODD, while others fall under the argumentative/defiant subtype.
- Tonic and phasic irritability characterize the angry/irritable subtype of ODD.
ODD vs. DMDD
- While temper outbursts and irritability occur in ODD and DMDD, they are more severe and frequent in DMDD.4
- ODD behaviors should occur at least once a week for at least six months and need only be confined to one setting to merit diagnosis, unlike with DMDD.
- The angry/irritable subtype of ODD is associated with increased risk for depression and anxiety.5
- ODD and ADHD are highly comorbid; ODD may be the most common comorbidity among children with ADHD.6
Age of Onset
Though ODD symptoms can appear during the preschool years, ODD typically develops a little bit later, generally after the onset of ADHD. ODD can also onset later in adolescence.
Irritability is one of the cardinal signs of the manic episodes that occur in bipolar disorder, which is characterized by extreme changes in mood and behavior. The following symptoms may accompany irritability during a manic episode:
- inflated self-esteem or grandiosity
- decreased need for sleep
- racing thoughts
- risky, impulsive behaviors
Additional Mood Characteristics
Irritability in bipolar disorder in episodic/phasic. When a child with bipolar disorder is euthymic (i.e., not in an episode of mania or depression), they are not irritable — a key factor that distinguishes bipolar disorder from DMDD and other conditions where irritability is tonic/chronic.
Age on Onset
Bipolar disorder generally emerges during adolescence or adulthood, though a portion of diagnosed patients had symptoms of the disorder before age 13.7
Associated Features and Risk Factors
- A family history of BPD greatly increases the odds that a patient will develop BPD.8
- Early onset depression and seasonal patterns to mood episodes may all be “yellow” flags for BPD.
While mostly thought of in terms of inattention, impulsivity, and hyperactivity, ADHD brings significant emotional regulation difficulties, including elevated levels of irritability, for nearly half of children with ADHD.9 In fact, many researchers consider emotional dysregulation to be a core feature of ADHD.
Additional Mood Characteristics
- Research indicates that about 30% of children with ADHD fit an angry/irritable profile. That is, they have high levels of anger, and take longer to return to baseline mood levels.10
- Symptoms of emotional lability (anger, irritability, low frustration tolerance, etc.) increase the severity of core ADHD symptoms in children.11
- Phasic irritability (i.e., temper outbursts) is linked to ADHD.12
- Irritability is mostly associated with ADHD combined type over the inattentive and hyperactive/impulsive types.13
ADHD is comorbid with other conditions where irritability is a common trait or symptom, like ODD and DMDD. Some symptoms of ADHD not tied to irritability, like accelerated speech, distractibility, and unusual energy, overlap with bipolar disorder.
Other Conditions Linked to Irritability
- Depression: Irritability is a symptom of depression in children and adolescents, but not in adults.14
- Generalized anxiety disorder (GAD): GAD is the only anxiety disorder in the DSM-5 wherein irritability is a listed symptom, though research links irritability to multiple anxiety disorders.15
Managing Irritability: Transdiagnostic Approaches and Future Directions
If irritability is tied to a condition, early identification is important to arrest further development of psychopathology over time.
Though irritability differs in severity, frequency, and persistence across conditions, clinicians can still refer to a basic set of principles and approaches for its management, regardless of condition. Ongoing research also points to potential pharmacological interventions for irritability.
Follow the FIRST Program
The FIRST program is a treatment approach designed to address behavioral and emotional problems, including irritability and anger, in children and adolescents.16 The five principles of FIRST are as follows:
- Feeling calm: Self-calming and relaxation techniques (e.g., breathing exercises, progressive muscle relaxation) can help relieve frustration, anger, and irritability in the moment.
- Increasing motivation: Children need praise, rewards, and other attractive motivators to reinforce desired behaviors over maladaptive ones.
- Repairing thoughts: Thoughts influence feelings and behaviors. Identifying distorted thoughts that may give way to feelings of irritability and frustration could help reduce those outcomes.
- Solving problems: Problem-solving is a valuable skill that can help children overcome the issues that can aggravate irritability and anger.
- Trying the opposite: Children should engage in activities that directly counter the behavioral and/or emotional problem.
Dialectical behavior therapy for children (DBT-C) is designed to treat severe emotional and behavioral dysregulation in youth ages 6 to 12. DBT-C comprises parent training, child counseling, and parent-child skills training. Combined, these components help youth self-regulate.
Findings from a recent study on DBT-C adapted for youth with DMDD (which currently has no empirically established treatments) are promising.17 In the small study, children who underwent DBT experienced greater symptom improvement compared to children in the non-DBT group. Parents and children in the DBT group also expressed higher treatment satisfaction than did participants in the non-DBT group.
Stimulants, selective serotonin reuptake inhibitors (SSRIs), and atypical antipsychotics show promise in treating irritability in children and teens.2 Stimulants are known to decrease irritability in children with ADHD alone and in those with comorbid DMDD.18 19 Risperidone is currently used to treat irritability across a wide range of conditions.
Recent research on citalopram, an antidepressant, points to new directions in potential treatments for irritability. In a small trial of youth with severe irritability symptoms who were pretreated with methylphenidate, those who took citalopram, as an add-on, saw a reduction in symptoms (including temper outbursts) compared to those who were given a placebo.20 More research is needed to understand the efficacy of these medications in reducing irritability.
Irritability in Children: Next Steps
- Free Download: How to Deal with Anger From Your Child
- Read: The ADHD-Anger Connection
- Read: When Angry Kids Lash Out — How to Defuse Explosive Reactions
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Emotion Regulation Difficulties in Youth: ADHD Irritability vs. DMDD vs. Bipolar Disorder” [Video Replay & Podcast #435] with William French, M.D., DFAACAP., which was broadcast on December 14, 2022.
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