Modular Psychotherapy Outcomes for Youth With Different Latent Profiles of Irritability and Emotion Dysregulation

On the regulation and dysregulation of emotions in child psychopathology: commentary on Blader et al. (2025)

Blader et al.'s (2025) recent annual review article makes an important contribution to the literature on emotion dysregulation in child and adolescent mental health. In addition to synthesizing the current evidence base, the authors put forth a cogent formalized view of emotion regulatory processes and how they go awry. Much has been written on emotion (dys)regulation and psychopathology (for overviews, see Lincoln et al., 2022; Paulus et al., 2021; Sheppes et al., 2015). It would therefore be reasonable to ask what novel contribution could be made by a new review article at this time. But for all that has been written, there is much work still to be done. Blader et al. (2025) admirably rise to meet this challenge. We hope this commentary amplifies and adds to their effort. Below, we reflect on a few aspects of their contribution and offer some further thoughts that may inform future work in this area.

Irritability as a Transdiagnostic Construct Across Childhood and Adolescence: A Systematic Review and Meta-analysis

This meta-analytic review examined irritability across childhood and adolescence as it relates to symptoms of common mental health disorders in these periods. Of key interest was whether the relationship between irritability and symptom severity varies according to symptom domain. This was tested at the level of broad symptom dimensions (internalizing versus externalizing problems) as well as discrete diagnostic domains (e.g., anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder; autism spectrum disorder). Following PRISMA guidelines, a systematic search of five databases was conducted to identify studies reporting on associations between irritability and mental health symptoms in samples of children aged 2-18 years. Meta-analytic tests based on random effects models examined concurrent and longitudinal associations between irritability and symptom severity. Meta-regression tested potential moderators including symptom domain, child age, sex, informant type, and study quality. 119 studies met inclusion criteria with a total of 122,456 participants. A significant and positive association was found between irritability and severity of concurrent overall psychopathology in the order of a moderate effect size, while small to moderate effect sizes characterized the association between irritability and later mental health outcomes in prospective data. Further variation in this association was seen across specific diagnostic domains and methodological moderators. Findings support the conceptualization of irritability as a transdiagnostic construct reflecting emotion dysregulation across diverse forms of psychopathology in childhood and adolescence. Further research into the risk mechanisms underlying irritability is needed, in addition to translational approaches to early intervention.

The Organization of Anxiety Symptoms Along the Threat Imminence Continuum

Pathological anxiety is highly prevalent, impairing, and often chronic. Yet, despite considerable research, mechanistic understanding of anxiety and its translation to clinical practice remain limited. Here, we first highlight two foundational complications that contribute to this gap: a reliance on a phenomenology-driven definition of pathological anxiety in neurobiological mechanistic research, and a limited understanding of the chronicity of anxiety symptom expression. We then posit that anxiety symptoms may reflect aberrant expression of otherwise normative defensive responses. Accordingly, we propose that threat imminence, an organizing dimension for normative defensive responses observed across species, may be applied to organize and understand anxiety symptoms along a temporal dimension of expression. Empirical evidence linking distinct anxiety symptoms and the aberrant expression of imminence-dependent defensive responses is reviewed, alongside the neural mechanisms which may underpin these cognitive, physiological, and behavioral responses. Drawing from extensive translational and clinical research, we suggest that understanding anxiety symptoms through this neurobiologically-informed framework may begin to overcome the conceptual complications hindering advancement in mechanistic research and clinical interventions for pathological anxiety.

A network approach to the investigation of childhood irritability: probing frustration using social stimuli

BACKGROUND

Self-regulation in early childhood develops within a social context. Variations in such development can be attributed to inter-individual behavioral differences, which can be captured both as facets of temperament and across a normal:abnormal dimensional spectrum. With increasing emphasis on irritability as a robust early-life transdiagnostic indicator of broad psychopathological risk, linkage to neural mechanisms is imperative. Currently, there is inconsistency in the identification of neural circuits that underlie irritability in children, especially in social contexts. This study aimed to address this gap by utilizing a functional magnetic resonance imaging (fMRI) paradigm to investigate pediatric anger/frustration using social stimuli.

METHODS

Seventy-three children (M = 6 years, SD = 0.565) were recruited from a larger longitudinal study on irritability development. Caregivers completed questionnaires assessing irritable temperament and clinical symptoms of irritability. Children participated in a frustration task during fMRI scanning that was designed to induce frustration through loss of a desired prize to an animated character. Data were analyzed using both general linear modeling (GLM) and independent components analysis (ICA) and examined from the temperament and clinical perspectives.

RESULTS

ICA results uncovered an overarching network structure above and beyond what was revealed by traditional GLM analyses. Results showed that greater temperamental irritability was associated with significantly diminished spatial extent of activation and low-frequency power in a network comprised of the posterior superior temporal sulcus (pSTS) and the precuneus (p < .05, FDR-corrected). However, greater severity along the spectrum of clinical expression of irritability was associated with significantly increased extent and intensity of spatial activation as well as low- and high-frequency neural signal power in the right caudate (p < .05, FDR-corrected).

CONCLUSIONS

Our findings point to specific neural circuitry underlying pediatric irritability in the context of frustration using social stimuli. Results suggest that a deliberate focus on the construction of network-based neurodevelopmental profiles and social interaction along the normal:abnormal irritability spectrum is warranted to further identify comprehensive transdiagnostic substrates of the irritability.

Predictive Utility of Irritability "In Context": Proof-of-Principle for an Early Childhood Mental Health Risk Calculator

OBJECTIVE

We provide proof-of-principle for a mental health risk calculator advancing clinical utility of the irritability construct for identification of young children at high risk for common, early onsetting syndromes.

METHOD

Data were harmonized from two longitudinal early childhood subsamples (total N = 403; 50.1% Male; 66.7% Nonwhite; Mage = 4.3 years). The independent subsamples were clinically enriched via disruptive behavior and violence (Subsample 1) and depression (Subsample 2). In longitudinal models, epidemiologic risk prediction methods for risk calculators were applied to test the utility of the transdiagnostic indicator, early childhood irritability, in the context of other developmental and social-ecological indicators to predict risk of internalizing/externalizing disorders at preadolescence (Mage = 9.9 years). Predictors were retained when they improved model discrimination (area under the receiver operating characteristic curve [AUC] and integrated discrimination index [IDI]) beyond the base demographic model.

RESULTS

Compared to the base model, the addition of early childhood irritability and adverse childhood experiences significantly improved the AUC (0.765) and IDI slope (0.192). Overall, 23% of preschoolers went on to develop a preadolescent internalizing/externalizing disorder. For preschoolers with both elevated irritability and adverse childhood experiences, the likelihood of an internalizing/externalizing disorder was 39-66%.

CONCLUSIONS

Predictive analytic tools enable personalized prediction of psychopathological risk for irritable young children, holding transformative potential for clinical translation.

A Delphi consensus among experts on assessment and treatment of disruptive mood dysregulation disorder

Objective

The aim of this study was to explore consensus among clinicians and researchers on how to assess and treat Disruptive Mood Dysregulation Disorder (DMDD).

Methods

The Delphi method was used to organize data collected from an initial sample of 23 child psychiatrists and psychologists. Three rounds of closed/open questions were needed to achieve the objective.

Results

Fifteen experts in the field completed the whole study. Finally, 122 proposals were validated and 5 were rejected. Globally, consensus was more easily reached on items regarding assessment than on those regarding treatment. Specifically, experts agreed that intensity, frequency, and impact of DMDD symptoms needed to be measured across settings, including with parents, siblings, peers, and teachers. While a low level of consensus emerged regarding optimal pharmacological treatment, the use of psychoeducation, behavior-focused therapies (e.g., dialectical behavior therapy, chain analysis, exposure, relaxation), and systemic approaches (parent management training, family therapy, parent-child interaction therapy) met with a high degree of consensus.

Conclusion

This study presents recommendations that reached a certain degree of consensus among researchers and clinicians regarding the assessment and treatment of youths with DMDD. These findings may be useful to clinicians working with this population and to researchers since they also highlight non-consensual areas that need to be further investigated.

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.

Latent classes of oppositional defiant disorder in adolescence and prediction to later psychopathology

Current conceptualizations of oppositional defiant disorder (ODD) place the symptoms of this disorder within three separate but related dimensions (i.e., angry/irritable mood, argumentative/defiant behavior, vindictiveness). Variable-centered models of these dimensions have yielded discrepant findings, limiting their clinical utility. The current study utilized person-centered latent class analysis based on self and parent report of ODD symptomatology from a community-based cohort study of 521 adolescents. We tested for sex, race, and age differences in the identified classes and investigated their ability to predict later symptoms of depression and conduct disorder (CD). Diagnostic information regarding ODD, depression, and CD were collected annually from adolescents (grades 6-9; 51.9% male; 48.7% White, 28.2% Black, 18.5% Asian) and a parent. Results provided evidence for three classes of ODD (high, medium, and low endorsement of symptoms), which demonstrated important developmental differences across time. Based on self-report, Black adolescents were more likely to be in the high and medium classes, while according to parent report, White adolescents were more likely to be in the high and medium classes. Membership in the high and medium classes predicted later increases in symptoms of depression and CD, with the high class showing the greatest risk for later psychopathology.