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Deciphering Irritability among Children: Causes and Connections to Comorbidities

What is Irritability?

Grouchy. Moody. Easily frustrated and annoyed. Short-tempered.

These signs can be characterized by anger, and can be faced by all young generations from years. Irritability is persistent, makes the situation intense, or leaves impacts on our functioning must be symptoms of normal adolescent development. Irritation is a common symptom of several mental disorders, including attention deficit hyperactivity disorder (ADHD), disruptive mood dysregulation disorder(DMDD) and bipolar disorder (BPD).

Step one in managing clinically significant irritability is to accurately trace it to the right condition. This requires careful differential diagnosis. Any child or teenager who faces severe irritability can take advantage by applying emotional and behavioral regulation skills.

Normal levels of irritability can be caused by stress, insufficient sleep and/or mood swings during puberty. Clinically significant levels of irritability can be reached when it is severe, persistent, and/or inconsistent in age and development. Severe irritability can affect as many as 5% of people.1 Youth are often referred to psychiatric services because of their irritability.2 Researchers believe that pathological irritability can be explained by brain processes that are impaired.

Frustrative Non Reward and Irritability

Irritability is when we are unable or unwilling to achieve the reward or goal we desire. This concept is known as frustrative-non-reward. Healthy brains know when to expect rewards and how they can be adjusted to make it easier to achieve a reward or goal (and avoid punishment). Researchers believe that irritable youth are more likely to experience frustration and not receive a reward.

Irritability, Threat-Processing Deficits

Aggression and anger are normal responses to threats. However, irritable children may misinterpret low-level stimuli or neutral stimuli as highly threatening. This could lead to aggression and temper outbursts.2 Researchers believe that children are more irritable when they have both reward-and threat-processing deficits.

Tonic Irritability vs. Phasic Irritability

It is particularly useful to diagnose irritability by looking at its persistence. Tonic (chronic) irritation is when anger, grouchiness and annoyance are persistent and part and parcel of a patient’s baseline mood. This type of irritability can predict future internalizing disorders like anxiety and depression.3

Temper outbursts, aggression, and other signs of irritability are referred to as phasic (or episodic). This dimension of irritability predicts the development of externalizing disorders such as ADHD and ODD.3

Irritability across Conditions: Distinguishing Characteristics

Irritation is a non-specific, transdiagnostic symptom that mental health professionals can use to diagnose patients with mental disorders. It’s like a fever to pediatricians. Irritation is a core sign of many mental disorders, just as fevers are a symptom of many illnesses and infections.

We possibly point out the irritability facing the diagnostic criteria and associated features conditions.


DMDD is characterized by severe, chronic irritability. This causes children to have outbursts that are outlandishly extreme and out of proportion to the trigger or situation. Outbursts may take the form of verbal rage, or physical aggression.

In response to concerns that some children with chronically irritable personalities were being wrongly diagnosed and/or treated as pediatric bipolar disorder,

Characteristics of the Mood

  • Temper outbursts should occur on average three to more times per week in at most two settings and for over one year to be eligible for a DMDD diagnosis.
  • Children who are suffering from DMDD must feel a persistent irritation, and an angry mood. DMDD is characterised by phasic irritability and tonic at the highest levels.

Associated Features

DMDD can co-occur alongside ADHD, conduct disorder, or major depressive disorder (MDD).

Age at Onset

DMDD can’t be diagnosed before age 6, but symptoms should present by age 10.


  • DMDD cannot co-occur alongside oppositional defiant disorder, intermittent explosive disorder (IED), and bipolar disorder.
  • If a child has had a manic episode or hypomanic episode, DMDD cannot diagnose.


A pattern that defines angry or irritable mood, argumentative and defiant behaviors, or somehow vindictiveness are symptoms of ODD. The ODD category includes the following symptoms:

  • often loses temper
  • It is often irritating or touchy.
  • Is often angry and resentful

Additional mood characteristics

  • In diagnostic criteria of ODD,children at least have one of four symptoms to diagnose it at its root. Some patients often fall under the irritable and angry type of ODD which is dangerous, others fall under the argumentative/defiant subtype of OCD.
  • The angry/irritable subtype is characterized by phasic irritability and tonic irritability.


  • ODD and DMDD can both have temper outbursts or irritability, but they are more frequent and severe in DMDD.4
  • ODD behaviors should be observed at least once per week for at most six months. They do not need to be restricted to one setting in order to merit diagnosis.

Associated Features

  • An increased risk of anxiety and depression is associated with ODD subtypes that are angry/irritable.5
  • ADHD and ODD are often comorbid. ODD could be the most common comorbidity in ADHD children.6

Age at Onset

ODD symptoms can be present in the preschool years. However, ODD usually develops after the onset ADHD. ODD symptoms can also develop later in adolescence.

Bipolar Disorder

Bipolar disorder is characterised by manic episodes, which are marked by extreme mood and behavior changes. Irritation during manic episodes may be accompanied by the following symptoms:

  • Inflated self-esteem or grandiosity
  • Reduced need for sleep
  • talkativeness
  • Racing thoughts
  • Distraction
  • Risky, impulsive behavior

Additional mood characteristics

Bipolar disorder is episodic/phasic. Bipolar disorder is distinguished from DMDD and other disorders where irritability can be tonic/chronic when a child is euthymic.

Age at Onset

Bipolar disorder usually manifests in adulthood or adolescence, but some patients were diagnosed before age 13.7

Associated Features and Risk Factors

  • BPD is more likely in patients with a family history.8
  • BPD may be a sign of early onset depression or seasonal patterns in mood episodes.


ADHD is often thought of as hyperactivity, inattention, impulsivity and hyperactivity. However, ADHD can cause significant emotional regulation problems, including increased levels of irritability for nearly half the children diagnosed.9 Many researchers believe that emotional dysregulation is a core feature in ADHD.

Additional mood characteristics

  • Research shows that around 30% of ADHD children are angry/irritable. This means that they are more likely to be angry than normal and to have a harder time returning to their baseline mood.10
  • Emotional lability symptoms (anger, irritability and low frustration tolerance) can be a sign of emotional instability. Core ADHD symptoms in children are more severe.11
  • ADHD is associated with phasic irritability (i.e. temper outbursts).12
  • Irritability is affiliated with ADHD inattentive and hyperactive/impulsive forms

Associated Features

ADHD can be comorbid with other conditions in which irritability is a common trait, such as ODD or DMDD. ADHD symptoms that are not related to irritability such as accelerated speech, distractibility and unusual energy overlap with bipolar disorder.

Other Conditions Related to Irritability

  • Depression: In children and adolescents, irritability can be a sign of depression. However, it is not common in adults.14
  • Generalized anxiety disorder (GAD). GAD is the only anxiety disorder in the DSM-5 Although irritability is listed as a symptom, research has linked irritability with multiple anxiety disorders.15

Managing Irritability: Transdiagnostic Methods and Future Directions

Early identification of irritability as a sign of a condition is crucial to stop the development and progression of psychopathology.

Although irritability can vary in severity, frequency, persistence, and duration, clinicians can still refer back to a basic set principles and approaches for its management regardless of condition. There are also potential pharmacological treatments for irritability.

Follow the FIRST Program

The FIRST program is a treatment method that addresses behavioral and emotional problems in children and teens, including anger and irritability.16 These are the five principles of FIRST:

  • Feeling calm: Relaxation techniques such as breathing exercises and progressive muscle relaxation can be used to relieve anger, frustration, and irritability.
  • Motivation: Children need praise, rewards and other attractive motivators in order to reinforce desirable behaviors over those that are not.
  • Restoring thoughts: Thoughts can influence emotions and behavior. Recognizing distorted thoughts that can lead to frustration and irritability could help you reduce these outcomes.
  • Solving problems: Children can learn to solve problems and help them overcome anger and irritability.
  • Try the opposite: Children should engage with activities that directly counter the emotional and/or behavioral problem.


Dialectical behavior therapy (DBT) for children is designed to treat severe emotional or behavioral dysregulation in youth aged 6-12 years old. DBT-C includes parent training, child counselling, and parent-child skill training. These components, when combined, help youth self-regulate.

Recent findings from a study on DBT-C adapted to youth with DMDD (which has no empirically proven treatment) are encouraging.17 The small study found that children who received DBT had greater symptom improvement than children who did not receive it. Children and parents in the DBT group were also more satisfied with their treatment than those in the non-DBT groups.


Children and teens are susceptible to irritability.2 Children with ADHD and comorbid DMDD have been shown to experience a decrease in irritability when taking stimulants.18 19 Risperidone can be used to treat irritability in a wide variety of conditions.

Recent research on citalopram (an antidepressant) points to new avenues for treating irritability. A small study of young people with severe irritability symptoms found that those who received citalopram as an add-on saw a reduction in their symptoms (including temper outbursts), compared to those who received a placebo.20 To understand the effectiveness of these medications in reducing irritability, more research is needed.

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    Deciphering Irritability among Children: Causes and Connections to Comorbidities