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

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Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention BETH-00899; No of Pages 15; 4C: Available online at www.sciencedirect.com ScienceDirect Behavior Therapy xx (xxxx) xxx www.elsevier.com/locate/bt Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive-Behavioral Intervention Spencer C. Evans Harvard University Jennifer B. Blossom Seattle Children’s Hospital and University of Washington School of Medicine Paula J. Fite University of Kansas depressive symptoms, anxiety, reactive aggression, opposi- Severe irritability is a common and clinically important tionality, intolerance of uncertainty, and poor emotion problem longitudinally associated with internalizing and coping. From T1 irritability to T2/T3 outcomes, mediation externalizing problems in children. To better understand was found for poor sadness coping leading to reactive these mechanisms and to inform treatment research, we tested aggression and oppositionality; poor anger coping to anxiety, cognitive-behavioral processes as candidate mediators in the depressive symptoms, and oppositionality; and intolerance of paths from irritability to later problems. Methods: A school uncertainty to anxiety. Results offer further evidence for sample (N = 238, 48% female, ages 8–10) was assessed at internalizing and externalizing outcomes of youth irritability ~6-month intervals in fall (T1) and spring (T2) of third to and new evidence suggesting underlying mechanisms. Irrita- fourth grade, and again the following fall (T3). Measures bility may confer risk for externalizing problems via poor assessed irritability (T1/predictor); anger and sadness sadness/anger coping, and for internalizing problems via poor coping, intolerance of uncertainty, and rumination; (T1– anger coping and intolerance of uncertainty. Theoretical T2/mediators); and anxiety, depressive symptoms, reac- models and psychosocial treatment should consider address- tive aggression, and oppositionality (T1–T3/outcomes). ing regulation of various unpleasant emotions as well as Focused cross-lagged panel models, controlling for gender psychological flexibility and tolerating uncertainty. and grade, were specified to examine full (XT1 ➔ MT2 ➔ YT3) and half (XT1 ➔ MT2; MT1 ➔ YT2) longitudinal mediation. Across one or more intervals, irritability predicted higher Keywords: irritability; dysregulation; treatment mechanisms; transdiagnostic; emotion regulation BROADLY DEFINED AS A PROPENSITY for experiencing The authors thank the students, teachers, staff, and administra- tors who participated in this research. We gratefully acknowledge anger, irritability is a universal human experience support from the American Psychological Foundation (Elizabeth with interindividual, intraindividual, and develop- Munsterberg Koppitz Child Psychology Graduate Fellowship to mental variability (Stringaris & Taylor, 2015). While SCE), University of Kansas (Lillian Jacobey Baur Early Childhood Fellowship to SCE, Doctoral Student Research Fund Awards to SCE normative irritability is transient and mild, severe and JBB, Pioneers Classes Dissertation Research Award to SCE, irritability can include aggression and is associated Faculty Research Fund Award to PJF), and AIM for Mental Health with depression, anxiety, and social and behavioral (AIM Fellowship to SCE). Address correspondence to Spencer Evans, 1040 William James problems in children and adolescents (e.g., Burke, Hall, 33 Kirkland Street, Cambridge, MA, 02138; e-mail: Hipwell, & Loeber, 2010; Evans, Pederson, Fite, [email protected]. Blossom, & Cooley, 2016; Vidal-Ribas, Brotman, 0005-7894/© 2019 Association for Behavioral and Cognitive Therapies. Valdivieso, Leibenluft, & Stringaris, 2016). Recent Published by Elsevier Ltd. All rights reserved. literature reviews (Brotman, Kircanski, & Leibenluft, Please cite this article as: S. C. Evans, and , Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive- Behavioral Intervention, Behavior Therapy, https://doi.org/10.1016/j.beth.2019.05.006 2 evans et al. 2017; Brotman, Kircanski, Stringaris, Pine, & may be complex and multifaceted, with multilevel Leibenluft, 2017; Evans et al., 2017; Stringaris, underpinnings (Lewandowski, Ongur, & Keshavan, Vidal-Ribas, Brotman, & Leibenluft, 2018)demon- 2018). Indeed, severe irritability is quite complex and strate the clinical and developmental significance of multifaceted, with great diversity in its clinical severe irritability. Further, irritability is a transdiag- manifestations (e.g., irritable mood, verbal aggres- nostic feature of over a dozen disorders (e.g., sion, physical aggression) and developmental out- oppositional defiant disorder [ODD], disruptive comes (e.g., depression, anxiety, ODD; Brotman, mood dysregulation disorder [DMDD], anxiety Kircanski, & Leibenluft, 2017; Stringaris & Taylor, disorders, depression) and an associated feature of 2015; Stringaris et al., 2018). Accordingly, it would many more (e.g., autism spectrum disorder [ASD], be useful to better understand the pathways from attention-deficit/hyperactivity disorder [ADHD]). irritability to its more severe internalizing and Clearly, irritability is a clinically important problem. externalizing outcomes (Vidal-Ribas et al., 2016). Unfortunately, extant research provides limited Brotman, Kircanski, Stringaris, et al.’s (2017) guidance to inform the treatment and conceptuali- translational model of irritability provides a useful zation of severe irritability in youth. Severe irritabil- framework through which to develop this kind of ity longitudinally predicts multiple internalizing and research to improve understanding, assessment, externalizing problems (Vidal-Ribas et al., 2016), and treatment. This model suggests that threat but little is known about how these developmental bias (defined as maladaptive attention to threat) pathways unfold or how treatments might address and aberrant frustrative nonreward (defined as them (Evans et al., 2017). In particular, there is a one’s response to blocked goal attainment) are key need for research to help identify specific emotion- processes underlying irritability (Brotman, Kircanski, regulatory skills and deficits that may offer tractable Stringaris, et al., 2017). In this way, irritability is not targets for psychotherapeutic intervention, before only a precursor to but also shares common irritability leads to subsequent problems with mood, underpinnings with anxiety (e.g., threat bias, anxiety, and behavioral disorders. common neural circuitry), depression (e.g., mood To this end, the present study explores the roles disturbance, negative affect), and aggression (e.g., of three candidate mediators—emotion coping, threat bias, and lowered threshold for annoyance and intolerance of uncertainty, and rumination—in the behavioral response). progression from irritability to anxiety, depressive Still, relatively little is known about the nature of symptoms, reactive aggression, and oppositional irritability’s associations with anxiety, aggression, behavior. In doing so, we adopt a dimensional, and depression. There is a considerable amount of transdiagnostic, experimental therapeutics frame- research on the psychological vulnerabilities under- work. Below we provide further rationale for this lying these internalizing and externalizing problems, approach, for the selected mediators, and for how many of which are transdiagnostic in character and they may relate to irritability as well as anxiety, may help account for the linkages to irritability. depression, and externalizing behaviors. Some of these processes may be especially relevant to irritability and may shed light on how and why it Exploring Candidate Mediators confers risk for future psychopathology. From an The logic of the present study is consistent with experimental therapeutics perspective, a better un- several recent recommendations, including those derstanding of these developmental pathways could for advancing evidence-based practice in youth help advance the treatment of irritability and the mental health (e.g., Ng & Weisz, 2016; Roberts, prevention of internalizing and externalizing disor- Blossom, Evans, Amaro, & Kanine, 2017) and for ders. Accordingly, we explore poor emotion coping, advancing the clinical science of irritability from a intolerance of uncertainty, and rumination as transdiagnostic perspective (Meyers, DeSerisy, & possible mediators in the progression from irritability Roy, 2017; Zachary & Jones, 2019). In particular, to subsequent internalizing and externalizing we adopt an experimental therapeutics framework problems. (Insel & Gogtay, 2014) from a youth psychother- apy perspective. Experimental therapeutics involves emotion coping identifying putative mechanisms of psychopathology, The capacity to experience and manage different developing interventions to target those mechanisms, emotions has important implications for psycho- testing whether the treatment exerts the hypothesized logical well-being. An inability to cope with effect, and evaluating whether this, in turn, leads to negative emotions can increase risk for both clinical improvement. Adopting such a paradigm internalizing and externalizing psychopathology entails several challenges for behavioral interventions (Compas et al., 2017). Irritability has been defined insofarasthe“target” of a behavioral manifestation as a propensity toward anger, which may lead to Please cite this article as: S. C. Evans, and , Exploring Longitudinal Mechanisms of Irritability in Children: Implications for Cognitive- Behavioral Intervention,
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