We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Now, I don't know if you have or have had teenagers of your own. But I know that I certainly did. Like every teenager who's ever been, there are times when there's a little bit of irritability. Teenagers be moody. Quick to snap or hard to appease. I guess that probably sounds familiar to a lot of people. But what happens when irritability goes beyond the usual ups and downs? It becomes persistent, intense, and there's struggles with daily life. It disrupts learning and daily functioning. It impacts on relationships and the family. How do we distinguish that everyday moodiness from something that's clinically significant? And why is that teenage period so significant in relation to irritability? The podcast will start to discuss questions like, what can clinicians, parents, and schools do to support young people who struggle with intense feelings? We'll be answering all these questions and more as we dive into the topic around how irritability impacts on daily lives for teenagers. The episode of Mind the Kids is called Irritability in Teens more than a Fight. I'm Mark Tebbs, I'm your host for today. I've spent my whole career working in mental health, from frontline service delivery, to director of commissioning, I'm currently chief exec of a charity, I'm a trustee of a mental health organisation, and a career coach. I'm delighted to be hosting these podcasts because it gives us an opportunity to talk to clinicians and academics at the forefront of research and really share their important work. So if you're a clinician, educator, parent, or just curious about adolescent mental health, I hope this discussion leaves you with new insights, some compassion, and maybe some practical tools. To help us understand the complex emotion of irritability, I'm joined by Dr. Jamilah Silver, an assistant professor of clinical psychology at the University of North Carolina, Chapel Hill. And she has dedicated her research to studying irritability and emotional regulation in young people. Jamilah is the lead author of the paper featured in ACAMH Children and Adolescent Mental Health Journal, entitled A Large Multinational Study of Irritability in Adolescence, which we'll be looking at today. Let's get started. Jamilah, welcome. It would be great if you could just introduce yourself, and maybe if there was a key collaborator that you worked with on the paper, it's an opportunity to give them a little bit of a name check. Of course. Really excited to be here and to chat about my research. My name is Jamilah Silver, and I'm currently an assistant professor at the University of North Carolina at Chapel Hill. I earned my PhD in clinical psychology at Stony Brook University, under the mentorship of Dr. Daniel Klein. My research really focused on irritability, emotion regulation, and early emerging risk factors for psychopathology. The project that we'll talk about today was truly an international collaboration. But I do want to shout out Dr. Argyris Stringaris. He was my lead mentor on this team and is currently at University College London, and he has been an exceptional mentor throughout my career. Brilliant. So I think in terms of the structure of the conversation, I think, we'll start just by talking about irritability more generally, and then we'll speak a little bit more in detail of your paper. What do we mean when we talk about irritability, what do we actually mean? Yeah, I think when clinicians and researchers are using the term irritability, we're not talking about one off bad day. We're really talking about this heightened proneness to anger. These are people who have a really lower threshold for feeling annoyed, for snapping, a tendency to react or have really strong reactions. And to have this level of irritability show up more often than is typical. So it's really about how easily anger is triggered and how frequently it reoccurs, which is why irritability can look like quick fire ups to seemingly small things that happen throughout the day. It could look like people being on edge or moody. But this construct becomes clinically meaningful when it's really frequent, and tense, prolonged, and it's impairing. It's disrupting things like school, friendships, sleep, family life. And so that sense irritability is both a state, so you're cranky today. And for some teens, it's a trait like vulnerability. So you're often quick to anger. That is how you are. And that trait aspect is what our study hopefully helps to illuminate across the countries. Great stuff. So that's really super clear, great definition. So why is irritability so common in that kind of adolescent period? Yeah, adolescent is the perfect storm for irritability. It's the perfect time that stacks a lot of ingredients that really lower frustration tolerance. Think biologically, we have brain systems that are targeting things like rewards and threats. They mature earlier than things like our prefrontal systems, that really help us regulate our impulses and our emotional surges. We also have hormonal shifts. We have the fact that we're fighting that school time start earlier. We're often seeing teenagers that are in chronic sleep debt, and each of these is just nudging reactivity upward just slightly. I think, socially during adolescence the stakes are quite high. There's peer status, there's identity exploration, academic pressures, there's family conversations around autonomy. And so developmentally, this is normal, but more emotional intensity, and more conflicts, and more opportunities arise for those kinds of misfires. So it's unsurprising that some levels of irritability are common in adolescents. The clinical question is not, does irritability happen? But more so, how often? How intense? How long? And how costly is it for the teen that's experiencing it? So it's a perfect storm of biological, social, and environmental factors. Exactly. Is irritability as a clinical phenomenon? Is it taken more seriously now? Or why should it be taken more seriously? It feels like it's a term that's come more prevalent in the research literature. Yeah, I think irritability has become more of a serious construct in psychology and psychiatry literature, specifically because it really shows strong links transdiagnostically. It's associated with depression, anxiety, disruptive mood dysregulation, conduct disorders, trauma. We see links to irritability, and a lot of the psychopathology or disorders that we're talking about, and we're seeing a lot of pervasive long-term outcomes when it comes to irritability. So we're seeing relationships with things like poor life satisfaction, more bullying, higher levels of psychopathology, higher levels of suicidality. And we're really seeing that irritability has the potential to signal high levels of distress and impairment. So I think researchers and clinicians broadly are starting to take it more seriously, because that means that we can screen for it earlier, and we can support adolescents or young children who might be struggling with this construct. So what sort of impacts does irritability have on daily life? I guess for the adolescent, but also the family situation. Yeah, And persistent irritability really taxes relationships. There's more conflict with parents and siblings. There's more ruptures when it comes to your friendships. Irritability could lead to things like misinterpreting social situations with teachers or peers. In the academic sense, it can really derail learning. It could be hard to concentrate when you're often on edge or irritable. It could disrupt your sleep, if you're ruminating before bed or after conflicts. And sometimes it can narrow adolescents activities. So maybe you avoid situations that have to set you off and now you're not engaging in as many situations as you could. Irritability also has associations with things like bullying experiences, lower life satisfaction. Two outcomes that I think have their own ripple effects on mental health and school engagement when you think about them in isolation. And I think just over time, the really small daily costs of irritability can accumulate, and it can do things like shape your self-concept. You just start to think of yourself as, "I'm always irritable. This is just who I am." And also just shape your peer reputations as well. They're hard to be around, they're nasty to be around, and we don't want to be around those levels of irritability, which ultimately can reinforce stress. And then you end up in this cycle of isolation away from peers. Sure. So, I think you've described some of the consequences of irritability, and that it's a natural kind of phenomenon that most teenagers maybe experience at some time. So at what point does it go from normal irritability to something that's more serious, and that maybe requires specialist intervention, clinical intervention? Yeah, I think to answer that question, you'd have to look at things like frequency, intensity, duration, impairment. So really thinking about things like, does irritability happen most days? Does it escalate fast? Does it last long? And does it interfere with things like school, sleep, friends, family, et cetera. So when irritability is daily and it's also disruptive, that's when we think about it's more on the concerning side and requires a check in or screening. Yeah. And I'm just wondering whether it shows up differently in boys and girls, that different ways that irritability is expressed in different genders? Yeah. The research on this is nuanced. So some studies are finding no major differences between boys and girls and overall irritability levels. Others are showing clear differences in how irritability changes over time in these certain groups. So generally speaking, the research shows that boys tend to show higher levels of irritability in childhood. But that girls start to show higher levels as they move into adolescence. And this shift may suggest that irritability may rise and persist longer for girls during the teenage years than it does for boys themselves. We also see differences in how irritability connects to other symptoms based on gender. So for girls, irritability tends to be linked more closely to internalising problems like depression, anxiety. But for boys, it's often more associated with things like externalising behaviours like aggression or defiance. So this distinction matters because it really highlights how irritability shows up in different genders, and how maybe adults or clinicians might respond to it. Yeah. So I'd like to turn a little bit more closely to your paper now. So your paper was a large multinational study of irritability in adolescence. So could you just give us a brief overview of what you set out to study and investigate? Yeah, so we ended up using the Programme for International Student Assessment, which I'll refer to as PISA going forward. And this was just a triannual study that was really for 15 and 16-year-olds. And it was known for testing constructs like reading, math, and science. But PISA also collects a lot of standardised information on students' experiences and well-being, which is where we were able to tap in. In 2018 when we pulled the data among the participating countries, nine of them actually administered data or questionnaires on irritability. And so we ended up taking that sample of about 56,000 adolescents from several countries. And we were focused on three things. We were focused on one, how common is irritability in each of these countries? Two, are girls higher than boys by self-report on irritability? And then three, we were also really interested in how irritability might relate to depression and anxiety and other outcomes, like life satisfaction, socioeconomic status, and bullying. And had any other studies tried to investigate that in the way that you just described [INAUDIBLE] kind of like way? Yeah, so we have very limited cross-cultural data on irritability. I don't think we have any other studies that have reached this scale. So 56,000 adolescents, we move far beyond a single clinic or simple community samples. I don't think other studies have had this cross-national reach. So we have nine culturally and economically diverse countries that provide just a test of generalizability for us to answer these questions. And so perhaps somewhere out there in the literature that I'm not aware of, there are some investigations cross-culturally of irritability, but I don't think it has reached this scope or level. And were there any other features of the sample? I'm just wondering whether it was predominantly from urban areas or rural areas. Were there any other features of the sample that were kind of interesting to note? Other aspects of the sample that I'll highlight is that gender distribution was quite balanced, so it was about 50% female overall. Also, the country spanned Europe, Asia, the Middle East, and Latin America. So we weren't just covering or capturing a single cultural script in that way. But that said, representation was still incomplete. So we didn't have any African sites in the data set, and middle to high income nations were overrepresented. So we're really careful when we're talking about the study not to over claim global coverage, because more work needs to be done in that area. Yeah. So still a huge study across multiple countries, but some notable limitations as well. So what did you find? What were the key results? Yeah, so in terms of similarities where we found two striking consistencies that emerged, there's first frequency. So in every country, the most common answer to this question about experiencing irritability was rarely to never. But about one third to nearly one half reported irritability at least weekly, so about 40%. And then about 10% of reported irritability daily. Secondly, we found striking similarities across countries in terms of associations. So irritability was most strongly related to depression and nervousness or anxiety. And girls had higher levels of irritability than boys across countries. So this really just underscores just across naturally, similarities and levels of self-reported irritability. So those rates were really consistent across the different countries that kind of 10% daily, and then a third showing some signs weekly. And what have you put that down to? What's your conclusion in terms of what that? Yeah, I think regardless of country, regardless of culture, I think it really just highlights the commonality of irritability among adolescents, and that this is a universal phenomenon. Adolescents around the world are experiencing irritability, and can be experiencing irritability at quite high levels. Some weekly, some at least daily. Yeah. And were there any differences between different countries? Yeah, so while average levels were similar for irritability, we did see some exploratory differences and some of our associations with outcomes. So when we were looking at pairwise comparisons, we saw that the link between irritability and bullying appeared stronger in countries like China and Bulgaria, and the negative link between irritability and life satisfaction looks stronger in countries like China and the UAE. So we treat these as just hypothesis generating findings because they weren't primary and we weren't able to test mechanisms. But they do invite future work on things like school climate, peer norms, and support systems, and how those things might differ in some of these other countries. So, are you saying that there's this universal kind of level of irritability that's very consistent, but the expression is different due to cultural factors? So maybe not the expression because we don't have data on the expression. But the way that irritability is linked to specific outcomes does differ across countries. So some countries have stronger links between irritability and things like bullying or life satisfaction. Whereas we might have seen those associations in other countries, but they might not have been as strong. And do you have tentative hypothesis around why that could be? I would have to tap into cultural factors. Maybe it's the case that where we're seeing stronger associations, these countries have different cultural expectations or norms around things like peers, support systems, school climate that may either amplify or buffer how irritability plays out at this interpersonal level. Yeah, sure. So I'm just wondering in terms of the methodology, were there any particular challenges in terms of measuring irritability across different nations? Is the term irritability kind of understood in very similar ways? I'm just wondering how you went about that? Yeah. So comparability is certainly hard. We only used a single self-report item for irritability. And while that's helpful for things like standardisation, it really sacrifices nuance. So things like intensity, duration, context, we weren't able to get at those kinds of questions. Self-report also introduces a lot of biases. So things like social desirability or the ability to recall how your symptoms were experienced. And then that cross-cultural work also adds another layer, things like translation, cultural semantics, response styles can also affect scores. So we mitigated some of these issues with things like how we weighted variables and the mixed effect models that we were able to use. But we are still limited in the fact that the field really needs to be using multi-item, multi-informing, and cross-culturally validated irritability measures to really formally test these relationships. Looking ahead, I'm just wondering what the main implications of your findings are, especially about global mental health. Are there implications of your study for global mental health research? Yeah, I think, first and foremost, at the clinical level, we really need to start treating irritability as a front door signal. This might be adding brief irritability screens when we're screening for other things like mood and anxiety. And when kiddos are reporting daily irritability, this might mean also assessing other impairment domains, like bullying, sleep coping skills. I think at the school and policy level, we at least specifically with this study, we could think about pairing anti-bullying programmes with things like emotion, skill curriculum, and things like attention and sleep could be factors that we pay attention to at the school level. And then research wise, I think we really just need globally to move beyond single items. And I also think we need to focus on how we can build validated and culturally adaptive scales so that we can answer questions like, when I say the word irritability doesn't mean the same thing across different cultures and different countries. And have you got further research that's planning to explore some of these issues or are you aware of other researchers that are taking those questions forward? Yeah, we are currently working on a project that looks at the affective reactivity index, which is our main measure of irritability here in the United States. And we are comparing basically measurement invariance across a bunch of different countries to answer that question of, are we measuring the same constructs in different countries? And do these items mean the same things when we're assessing them in different countries? So we should get a little bit of data about what that looks like. And if irritability is looking the same here in the US as it does in other countries. So, I guess as a parent, we all have that kind of dilemma, don't we? So, is our teenager just being moody? Has it moved over into something that's a little bit more of serious? So how does a parent navigate when it's kind of crossed over from being normal moodiness to something that's a little bit more serious? Yeah, that's a great question. I think everyone feels irritable sometimes. We all have our cranky days, and that's a normal and often situational emotion that's often tied to things like feeling tired, feeling stressed, feeling frustrated. I think that clinical irritability, on the other hand, is something that's a little bit more chronic and intense and impairing. It shows up frequently, it shows up across settings, and it really impacts the functioning or relationships that your kiddo might be having. For talking about duration and frequency, occasional bad days are part of a normal mood variation. We all have them. Irritability becomes concerning when it's persistent. Is your kiddo having irritability most days for months at a time? When we're thinking about things like intensity, clinical significant irritability often feels disproportionate to whatever is happening. So these are like big emotional reactions to really small frustrations. Context is also important. So if irritability is something that's occurring across multiple settings, you're seeing it at home, you're seeing it at school, you're seeing it with their peers, rather than just one situation, that's another flag to pay attention to. And then impairment. Irritability at a clinical level often leads to significant impairment. These are things like having conflicts at school, having school difficulties, a lot of conflicts or family strain at home, or just if you notice that your child seems to be having a lot of emotional distress. So I'm wondering how it shows up in those different settings. So I'm particularly thinking about schools, we have a lot of teachers and educational psychologists that are listening. So how would that show up in that school environment? Yeah. So in the classroom, some things that teachers might notice are things like, our kiddos becoming frequently frustrated over really small challenges? Are you noticing that your kiddos are having really sudden emotional outbursts, or that they're becoming tearful? Are you noticing that your kiddos in the classroom are having a very low tolerance for things like transitions, or things like unexpected changes? Do you have kiddos that might be perceiving your neutral feedback as things that are criticism or personal attacks? And then also you can look for symptoms of withdrawal or shut down. Kids who shut down after conflict. So this is not just defiance. These are kids that remove themselves from situations or tend to shut down completely after there's been some conflict or altercation. And before we get to a kind of clinical setting, are there things that teachers can do? Are there any recommendations that you could advise teachers around management and support irritability? Yeah. One thing that's helpful is keeping routines predictable and having kids know that transitions are coming up. Another thing that's helpful is focusing on setting limits, but doing so in a way that is in a calm and neutral tone. Validating emotions is also super important, saying things like, "I can see why that was frustrating," before you moved to redirecting or implementing a consequence. And then also modelling is something that is super important. So being able to reinforce those regulation efforts is going to be very helpful in the classroom setting. And as a teacher, you can model some of those emotion regulation techniques, whether it's deep breathing, whether it's taking a moment for yourself, whether it's going to get a drink of water. You can model those regulation efforts so that students can then mimic those when they're feeling frustrated or irritable. That's really helpful. I guess, if it then does get to the point where children and adolescents are being referred into a clinical services for assessments, how is zero stability assessed? And are there any kind of limitations in the way that irritability is currently assessed or supported? Yeah, unfortunately, because irritability cuts across diagnoses, like ADHD, depression, anxiety, PTSD, we historically overlook irritability or we bundle it up into other conditions. And so in the clinical setting, we don't treat symptoms, we treat diagnoses, and that makes it really hard to say we're going to treat irritability. Instead a clinician might say, we're going to treat depression. We're going to treat anxiety. So viewing it as a transdiagnostic construct, really is going to help clinicians be able to understand this kind of underlying emotion dysregulation that's occurring within the context of these diagnoses, and then hopefully allow us to be able to move to assessing irritability explicitly, instead of just bundling it up into the diagnoses that we typically do. So how would that change improve things? Yeah. If we are able to separate irritability from other disorders or if we're able to treat symptoms, we can start to look at irritability as an early warning sign in and of itself, a signal that, let's say that emotion regulation systems aren't working efficiently. And then we can treat irritability as the clinical problem as opposed to waiting for a full-blown disorder to come up or present itself. So it just allows that kind of early recognition and early intervention? Precisely. Brilliant. If listeners want to find out a little bit more about you or your work, is there link that they could follow if they want to find out a little bit more about what you're working on? Yeah. So I direct the Developmental Research in Irritability and Psychopathology Lab at University of North Carolina, Chapel Hill. And we really are starting to focus on how irritability develops from early childhood through adolescence, and how things like biological, family, and environmental factors may interact to shape the course of irritability. So you're able to find me at driplab.unc.edu. That's driplab.unc.edu. And that website will lay out things like collaboration and mentorship. We'll also lay out our past research initiatives and the initiatives that we're looking forward to on take in the future. We're coming to the end of the podcast. I'm just wondering whether there's a final or take home message, a final message for our listeners? Final message. Yeah. Irritability matters. Irritability should be taken quite seriously and is quite important clinical phenomenon. And we're seeing that irritability matters beyond the United States. This is a global construct that has serious implications for teens, both in the US and outside the US and other countries. So I think research should really focus on what those relationships look like and how we can better treat irritability across contexts. Brilliant. Thank you so much for your time. Really interesting conversation. Thank you. Cool. What a great way to kick off the new series. Thank you so much for listening. As always, do leave comments, reviews, and suggestions, and please share with colleagues. If you have an ACAMH Learn account, which is free, from www.acamhlearn.org, you'll be able to get a free CPD/CME certificate for listening to any of the podcasts. Next week, we'll be going to Montreal and Canada to learn about how autistic children can spontaneously use language that aren't spoken at home, as I talked to Alexia Ostrolenk and David Gagnon. [AUDIO LOGO]