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.

By William French, M.D., DFAACAP Verified Updated on April 12, 2023

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

[Read: Top Emotion Regulation Difficulties for Youth with ADHD]

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.

[Read: Why Is My Child So Angry and Defiant?]

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.

DMDD

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.

Mood Characteristics

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.

Associated Features

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.

Exclusions

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.

ODD

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.

Associated Features

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.

Bipolar Disorder

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
talkativeness
racing thoughts
distractibility
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.

ADHD

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

Associated Features

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.

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.

DBT-C

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.

Medications

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.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

View Article Sources

¹Cornacchio, D., Crum, K. I., Coxe, S., Pincus, D. B., & Comer, J. S. (2016). Irritability and Severity of Anxious Symptomatology Among Youth With Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 55(1), 54–61. https://doi.org/10.1016/j.jaac.2015.10.007

²Brotman, M. A., Kircanski, K., Stringaris, A., Pine, D. S., & Leibenluft, E. (2017). Irritability in Youths: A Translational Model. The American journal of psychiatry, 174(6), 520–532. https://doi.org/10.1176/appi.ajp.2016.16070839

³ Hawes M. T., Carlson G. A., Finsaas M. C., Olino T. M., Seely J. R., Klein D. N. (2020). Dimensions of irritability in adolescents: Longitudinal associations with psychopathology in adulthood. Psychological Medicine, 50(16), 2759–2767. https://doi.org/10.1017/S0033291719002903

⁴Roy, A. K., Lopes, V., & Klein, R. G. (2014). Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth. The American journal of psychiatry, 171(9), 918–924. https://doi.org/10.1176/appi.ajp.2014.13101301

⁵Déry, M., Lapalme, M., Jagiellowicz, J., Poirier, M., Temcheff, C., & Toupin, J. (2017). Predicting Depression and Anxiety from Oppositional Defiant Disorder Symptoms in Elementary School-Age Girls and Boys with Conduct Problems. Child psychiatry and human development, 48(1), 53–62. https://doi.org/10.1007/s10578-016-0652-5

⁶Noordermeer, S. D. S., Luman, M., Weeda, W. D., Buitelaar, J. K., Richards, J. S., Hartman, C. A., Hoekstra, P. J., Franke, B., Heslenfeld, D. J., & Oosterlaan, J. (2017). Risk factors for comorbid oppositional defiant disorder in attention-deficit/hyperactivity disorder. European child & adolescent psychiatry, 26(10), 1155–1164. https://doi.org/10.1007/s00787-017-0972-4

⁷Perlis, R. H., Miyahara, S., Marangell, L. B., Wisniewski, S. R., Ostacher, M., DelBello, M. P., Bowden, C. L., Sachs, G. S., Nierenberg, A. A., & STEP-BD Investigators (2004). Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biological psychiatry, 55(9), 875–881. https://doi.org/10.1016/j.biopsych.2004.01.022

⁸Goldstein, B. I., & Birmaher, B. (2012). Prevalence, clinical presentation and differential diagnosis of pediatric bipolar disorder. The Israel journal of psychiatry and related sciences, 49(1), 3–14.

⁹Baweja, R., Waschbusch, D. A., Pelham, W. E., 3rd, Pelham, W. E., Jr, & Waxmonsky, J. G. (2021). The Impact of Persistent Irritability on the Medication Treatment of Paediatric Attention Deficit Hyperactivity Disorder. Frontiers in psychiatry, 12, 699687. https://doi.org/10.3389/fpsyt.2021.699687

¹⁰Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological assessment, 31(2), 236–247. https://doi.org/10.1037/pas0000664

¹¹Sobanski, E., Banaschewski, T., Asherson, P., Buitelaar, J., Chen, W., Franke, B., Holtmann, M., Krumm, B., Sergeant, J., Sonuga-Barke, E., Stringaris, A., Taylor, E., Anney, R., Ebstein, R. P., Gill, M., Miranda, A., Mulas, F., Oades, R. D., Roeyers, H., Rothenberger, A., … Faraone, S. V. (2010). Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. Journal of child psychology and psychiatry, and allied disciplines, 51(8), 915–923. https://doi.org/10.1111/j.1469-7610.2010.02217.x

¹²Cardinale, E. M., Freitag, G. F., Brotman, M. A., Pine, D. S., Leibenluft, E., & Kircanski, K. (2021). Phasic Versus Tonic Irritability: Differential Associations With Attention-Deficit/Hyperactivity Disorder Symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 60(12), 1513–1523. https://doi.org/10.1016/j.jaac.2020.11.022

¹³Eyre, O., Langley, K., Stringaris, A., Leibenluft, E., Collishaw, S., & Thapar, A. (2017). Irritability in ADHD: Associations with depression liability. Journal of affective disorders, 215, 281–287. https://doi.org/10.1016/j.jad.2017.03.050

¹⁴American Psychiatric Association. (2013). Major depressive disorder. In Diagnostic and statistical manual of mental disorders (5th ed.).

¹⁵Cornacchio, D., Crum, K. I., Coxe, S., Pincus, D. B., & Comer, J. S. (2016). Irritability and Severity of Anxious Symptomatology Among Youth With Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 55(1), 54–61. https://doi.org/10.1016/j.jaac.2015.10.007

¹⁶Weisz, J. R., & Bearman, S. K. (2020). Principle-guided psychotherapy for children and adolescents: The FIRST program for behavioral and emotional problems. The Guilford Press.

¹⁷Perepletchikova, F., Nathanson, D., Axelrod, S. R., Merrill, C., Walker, A., Grossman, M., Rebeta, J., Scahill, L., Kaufman, J., Flye, B., Mauer, E., & Walkup, J. (2017). Randomized Clinical Trial of Dialectical Behavior Therapy for Preadolescent Children With Disruptive Mood Dysregulation Disorder: Feasibility and Outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 56(10), 832–840. https://doi.org/10.1016/j.jaac.2017.07.789

¹⁸Fernández de la Cruz, L., Simonoff, E., McGough, J. J., Halperin, J. M., Arnold, L. E., & Stringaris, A. (2015). Treatment of children with attention-deficit/hyperactivity disorder (ADHD) and irritability: results from the multimodal treatment study of children with ADHD (MTA). Journal of the American Academy of Child and Adolescent Psychiatry, 54(1), 62–70.e3. https://doi.org/10.1016/j.jaac.2014.10.006

¹⁹Baweja, R., Belin, P. J., Humphrey, H. H., Babocsai, L., Pariseau, M. E., Waschbusch, D. A., Hoffman, M. T., Akinnusi, O. O., Haak, J. L., Pelham, W. E., & Waxmonsky, J. G. (2016). The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School. Journal of child and adolescent psychopharmacology, 26(2), 154–163. https://doi.org/10.1089/cap.2015.0053

²⁰Towbin, K., Vidal-Ribas, P., Brotman, M. A., Pickles, A., Miller, K. V., Kaiser, A., Vitale, A. D., Engel, C., Overman, G. P., Davis, M., Lee, B., McNeil, C., Wheeler, W., Yokum, C. H., Haring, C. T., Roule, A., Wambach, C. G., Sharif-Askary, B., Pine, D. S., Leibenluft, E., … Stringaris, A. (2020). A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. Journal of the American Academy of Child and Adolescent Psychiatry, 59(3), 350–361. https://doi.org/10.1016/j.jaac.2019.05.015