Irritability and Maladaptation Among Children: The Utility of Chinese Versions of the Affective Reactivity Index and Aberrant Behavior Checklist-Irritability Subscale

Abstract

Objectives:

Irritability is among the most bothersome emotional symptoms in children. It often leads to mental health services referral, significant impairment, and distress to their families. Although there is increasing scientific evidence supporting the existence of extreme irritability in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnosis of disruptive mood dysregulation disorder, few studies have investigated the measurement of irritability in children. This pilot study aimed to examine the psychometric properties of the Chinese version of the Affective Reactivity Index (ARI) and the Aberrant Behavior Checklist (ABC)-irritability subscale. In addition, we investigated adaptive difficulties among children with irritability.

Methods:

A total of 97 children and adolescents 6 to 17 years of age (M = 10.20, SD = 2.70) were recruited from the psychiatric outpatient department of a university hospital in Taipei. The participants completed the Chinese version of the ARI self-report form and the Social Adjustment Inventory for Children and Adolescents (SAICA). Their parents completed the ARI parent report form, the Chinese version of the ABC-irritability subscale, and the Child Behavior Checklist. Diagnostic interviews were administered based on diagnostic criteria of DSM-5 to confirm the participants' psychiatric diagnoses.

Results:

The Chinese ABC-irritability subscale and the parent and self-report scales of the Chinese ARI showed good test–retest reliability, internal consistency, and concurrent validity. Scores from the ABC-irritability subscale and two forms of the ARI were all significantly correlated with aggressive behaviors, anxious/depressed symptoms, and social problems. In addition, irritability among children was significantly associated with maladjustment in school, with peer problems, and with problems at home.

Conclusions:

Our findings suggest that irritability may be associated with impaired social adaptive functioning among children and adolescents. The Chinese version of the ARI and the ABC-irritability subscale are useful for measuring irritability in both clinical and research settings in the Chinese population.

Introduction

Irritability, a proneness to experience extraordinary emotional reactions in response to frustration, is one of the most bothersome emotional symptoms in children and adolescents. In previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association 2000), irritability was presented as part of the clinical manifestation of several different psychiatric disorders, including the mood and disruptive disorder sections, such as bipolar disorder, dysthymic disorder, and oppositional defiant disorder (ODD). In addition, severe irritability and the related aggressions among children often lead to referral for mental health services, significant impairment, and distress to the patients' families (Peterson et al. 1996; Collishaw et al. 2010; Copeland et al. 2013). However, clinicians and researchers have not paid adequate attention to irritability until recent decades. Emerging evidence shows that severe chronic irritability can be differentiated from other psychiatric disorders by its pathophysiology and longitudinal course (Vidal-Ribas et al. 2016). A new diagnosis, disruptive mood dysregulation disorder (DMDD), was proposed in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) (American Psychiatric Association 2013), and there has been increased scientific focus on it. Nevertheless, investigations of the measurement of irritability have been scarce.

The Affective Reactivity Index (ARI), developed in 2012, is the first inventory that specifically assesses severity of chronic irritability among children and adolescents (Stringaris et al. 2012a). This instrument evaluates irritability through three aspects: threshold, frequency, and duration of angry reactions. The strengths of the ARI include its inclusion of both parent-report and self-report versions that measure identical items. Since irritable mood in children may not accompany aggressive behaviors and therefore may not always be observed by parents, the self-report form questionnaire could measure a child's subjective feelings. Another widely used irritability rating scale is the Aberrant Behavior Checklist (ABC)-irritability subscale, primarily designed to assess treatment effects on individuals with developmental disabilities, which is completed by caregivers (Aman et al. 1985b). The ABC-irritability subscale consists of items that assess not only irritable mood but also acts of aggression. It has been proved to be a valid and reliable tool for research purposes in children with severe irritability (Krieger et al. 2011).

The current pilot study was mainly designed to examine the psychometric properties of the Chinese version of the ARI and the ABC-irritability subscale among children and adolescents in Taiwan. It is of great clinical and research importance to establish well-validated irritability rating instruments for several reasons. First, such instruments could help to quantify the severity of irritability and to serve as a reference for clinicians to consider further approaches when a patient's level of irritability reaches a pathological point. Second, in both clinical and research settings, the instruments could provide a reliable way to evaluate treatment effects on irritability. Third, since there is still little information about whether the mechanisms of irritability in different psychiatric diagnoses are the same or not, such instruments could help researchers analyze symptom profiles of irritability in patients with different diagnostic entities. The phenotypic fingerprints of irritability in different populations may help researchers explore the underlying etiologies of irritability.

The second aim of this study was to investigate the association between irritability and adaptive functioning. Previous literature has shown that irritability among children may lead to general functional impairment (Copeland et al. 2013; Dougherty et al. 2014; Deveney et al. 2015). However, limited research has focused on the subjective burden of social maladjustment due to irritability in youth. In this study, we adopted the self-reported questionnaire, the Social Adjustment Inventory for Children and Adolescents (SAICA) (John et al. 1987), to explore the impact of irritability on different domains of adaptive functioning. We expected that the results would provide useful information for planning treatment and a greater understanding of the psychopathology of childhood irritability.

Methods

Participants and procedures

Between June 2016 and November 2017, 83 children and adolescents, 6–17 years of age were recruited from the psychiatric outpatient clinic of a university hospital in Taipei. We also invited 14 healthy volunteers, who were the children of medical staff members, to enter this study. The healthy volunteers had no history of neurodevelopmental disorders; they were evaluated by a child psychiatrist with psychiatric open-ended interviews and did not meet the criteria for any neuropsychiatric disorders. All participants completed the Chinese version of the ARI self-report form, and the SAICA. In addition, all parents completed the Chinese version of the ABC-irritability subscale, the ARI parent report form, and the Child Behavior Checklist (CBCL). To investigate the test–retest reliability of the Chinese version ABC-irritability subscale and the ARI, 62 participants and their parents were invited to be retested with these two inventories two weeks after the initial assessment.

In addition, all patients who had never visited our child psychiatric outpatient department had a diagnostic interview and an intelligence test. All diagnostic interviews were administered by the principal investigator, a senior child psychiatrist (C.-B.Y.), and one clinical psychologist, based on the DSM-5. Information was gathered from the children, parents, and teachers, to assess crossdomain impairments. Full-scale IQ was measured with the Wechsler Intelligence Scale for Children 4th edition (WISC IV)-Chinese version (Wechsler 2007).

Before being recruited for the study, all patients and their parents provided written informed consent after the study had been thoroughly explained to them. The study was approved by the Institutional Review Board of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

With the consent of the authors of the original ARI and ABC, we translated these two inventories into Chinese. The translation and back translation were performed independently by two bilingual child psychiatrists. Two clinical psychologists reviewed the results to confirm the linguistic and content validity of the final version.

Measures

Affective Reactivity Index

The ARI was created as a dimensional measurement of irritability with both parent-report and self-report form (Stringaris et al. 2012a). This questionnaire, assessing for symptoms of irritability in the previous 6 months, is composed of six items, and the seventh item on functional impairment is rated on a three-point scale (ranging from 0 for “not true” to 2 for “certainly true”). The reliability and validity of the ARI in typically developed children has been previously reported (Stringaris et al. 2012a; Mulraney et al. 2014). The sum of scores of the first six items was used in this present study.

ABC-irritability subscale

The ABC is an instrument developed for assessing maladaptive behaviors in individuals with developmental disabilities (Aman et al. 1985b). However, its irritability subscale is a proven well-validated and widely used measure for rating irritability among otherwise normally developed children (Krieger et al. 2011). This subscale consists of 15 questions about irritability, aggression, tantrums, agitation, and unstable mood. The items are rated on a 4-point Likert scale (ranging from 0 to 3), with higher scores indicating greater severity.

Child Behavior Checklist

The CBCL, which consists of 118 items, is a parent-report rating scale assessing a broad range of psychopathology in children within the past 6 months (Achenbach 1991). Each item was scored from 0 (“not true”), to 1 (“somewhat or sometimes true”), and to 2 (“very true or often true”). In the current investigation, the sum score of three items extracted from the CBCL (“temper tantrums or hot temper,” “stubborn, sullen or irritable,” and “sudden changes in mood or feelings”), which was used to measure irritability in past studies (Stringaris et al. 2012b; Aebi et al. 2013; Wiggins et al. 2014; Roberson-Nay et al. 2015), was used to examine concurrent validity of the ARI and the ABC-irritability subscale. In addition, three subscales of the CBCL (aggressive behavior, anxious/depressed symptoms, and social problems) were used to test convergent validity of the ABC-irritability subscale and the ARI.

Social Adjustment Inventory for Children and Adolescents

The SAICA was designed for children and adolescents 6–18 years of age, and provided a systematic evaluation of children's and adolescents' adaptive functioning (John et al. 1987). It assessed social adjustment in four major role areas: school, spare-time activities, peer relations, and home life. The scoring of each item ranges from 1 for positive/not a problem, to 4 for negative/severe problem. The children or adolescents with higher scores had either poorer functioning or more severe problems in the assessed domain. Previous studies reported that the Chinese version of the SAICA was a reliable and valid instrument in clinical studies in Taiwan (Gau et al. 2006).

Statistical analyses

All statistical analyses were performed using SPSS software version 17 (SPSS, Inc, Chicago, IL). Cronbach's alpha (α) was used to assess the internal consistency of the Chinese version ARI and the ABC-irritability subscale. The test–retest reliability of these two irritability scales was assessed using the intraclass correlation coefficient (ICC) and its 95% confidence interval (CI). To examine the crossinformant agreement of ARI, repeated measures t-tests were used to compare the item mean between parent- and self-reported data. Pearson correlations (r) between the two forms of ARI and ABC-irritability subscale were also calculated. To test the validity of these two inventories in discriminating between children with different levels of irritability, analysis of variance was used to compare scores on the ARI and the ABC-irritability subscale among healthy volunteers, youths with ODD, and youth with DMDD, with post hoc testing between groups. The concurrent and convergent validity of the Chinese version ABC-irritability subscale and ARI in this sample was tested by their Pearson correlations (r) with irritability, aggressive behavior, anxious/depressed symptoms, and social problem subscales derived from the CBCL. Linear regression was also used to explore the relationship between the irritability and social adjustment functioning. Statistical significance was set at p < 0.05. A Bonferroni correction was made for multiple comparisons in correlation analyses with the corrected statistical significance as p < 0.00625.

Results

Patient characteristics

The characteristics of the sample and the subgroup with retest evaluation are shown in Table 1. The mean age of the sample group (n = 97) was 10.20 years (SD = 2.70; range 6–17) with 73 (75.3%) boys. Most of the subjects lived with both parents (n = 85, 87.6%), had one sibling (n = 63, 64.9%), and had a diagnosis of attention-deficit/hyperactivity disorder (n = 70, 72.2%). The demographics and psychiatric diagnoses of the retest subgroup were similar to those of the larger sample.

Table 1.

Characteristics of the Study Participants

	Total sample (n = 97)	Test–retest sample (n = 62)
	n (%)
Age (years), mean (SD)	10.20 (2.70)	10.72 (2.79)
Sex
Male	73 (75.3)	44 (71.0)
Female	24 (24.7)	18 (29.0)
Full-scale IQ	(n = 79)	(n = 45)
mean (SD)	100.91 (11.57)	98.78 (11.06)
Psychiatric diagnoses
ADHD	70 (72.2)	39 (62.9)
ODD	11 (11.3)	5 (8.1)
CD	1 (1.0)	1 (1.6)
Tourette's disorder	4 (4.1)	2 (3.2)
ASD	21 (21.6)	17 (27.4)
Anxiety disorder	4 (4.1)	3 (4.8)
Depressive disorder	5 (5.2)	2 (3.2)
DMDD	12 (12.4)	5 (8.1)
Writing disorder	2 (2.1)	0
Healthy volunteer	14 (14.4)	14 (22.6)
Family composition
Living with both parents	85 (87.6)	51 (82.3)
Living with father only	1 (1.0)	1 (1.6)
Living with mother only	11 (11.3)	10 (16.1)
No. of siblings
No siblings	18 (18.6)	14 (22.6)
One sibling	63 (64.9)	41 (66.1)
Two siblings	13 (13.4)	6 (9.7)
Three siblings	3 (3.1)	1 (1.6)

ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; CD, conduct disorder; DMDD, disruptive mood dysregulation disorder; IQ, intelligence quotient; ODD, oppositional defiant disorder.

Internal consistency and test–retest reliability of the Chinese ARI and ABC-irritability subscale

The Chinese ABC-irritability subscale demonstrated high internal consistency (α = 0.92) and good test–retest reliability (ICC = 0.87, 95% CI 0.78–0.92). For the Chinese ARI, the internal consistency was good, as indicated by a Cronbach's α of 0.91 for the parent and 0.86 for the self-report form. The parent-report ARI has higher 2-week test–retest reliability than the self-report form (ICC = 0.82, 95% CI 0.71–0.88, and ICC = 0.66, 95% CI 0.50–0.78, respectively). For the subjects with autism spectrum disorder in our sample (n = 21), the self-report ARI showed high internal consistency (α = 0.87), but modest test–retest reliability (ICC = 0.51, 95% CI 0.06–0.79).

Correlation between the Chinese ABC-irritability subscale and ARI, and comparison between parent and child ratings on the ARI

The Chinese ABC-irritability subscale score and scores from parent and self-report ARI forms significantly correlated with each other in our sample. The two scales rated by parents, ABC-irritability subscale and parent-report ARI, were highly correlated (r = 0.76, p < 0.001). There was moderate crossinformant agreement between self-parent report dyads in the ARI (r = 0.44, p < 0.001), as well as moderate correlation between the self-report ARI and ABC-irritability subscale (r = 0.31, p = 0.002). The comparison of item mean between parent-report and self-report form of the ARI are presented in Table 2. Except for the first item, “Easily annoyed by others,” there are no statistically significant differences for the five remaining items.

Table 2.

Comparison of Parent Report and Self-Report Forms on Each Item of the Affective Reactivity Index (n = 97)

	Parent-report	Self-report
	Mean (SD)		t	p
Easily annoyed by others	1.08 (0.73)	0.86 (0.78)	2.71	0.008
Often lose temper	0.95 (0.78)	0.93 (0.81)	0.25	0.807
Stay angry for a long time	0.56 (0.74)	0.66 (0.80)	−0.99	0.325
Angry most of the time	0.34 (0.61)	0.35 (0.61)	−0.13	0.894
Get angry frequently	0.63 (0.71)	0.68 (0.77)	−0.61	0.544
Lose temper easily	0.86 (0.75)	0.70 (0.78)	1.68	0.096

Validity of the Chinese ABC-irritability subscale and ARI

Table 3 shows the differences of the Chinese ABC-irritability subscale, and parent and self-report ARI scores among healthy volunteers, children with ODD, and children with DMDD in our sample. For each scale, children with DMDD had the highest scores and healthy volunteers had the lowest scores. All individual comparisons in post hoc analyses were significantly different on the ABC-irritability subscale and the parent-report ARI. For the self-report ARI, youths with DMDD showed significantly more irritability than did healthy volunteers. However, the differences between DMDD and ODD, and the difference between ODD and healthy volunteers were not significant in the self-report ARI.

Table 3.

Mean of the Aberrant Behavior Checklist-Irritability Subscale and the Affective Reactivity Index Scores by Diagnostic Group

	DMDD (n = 12)	ODD (n = 11)	HV (n = 14)
	Mean (SD)			F	p	Scheffé post hoc
ABC-irritability subscale	19.75 (7.74)	10.91 (8.96)	1.71 (2.46)	23.27	<0.001	D > O^; D > H^; O > H^
ARI total score
Parent-report	7.92 (2.81)	4.45 (2.91)	1.64 (1.91)	19.76	<0.001	D > O^; D > H^; O > H^
Self-report	6.33 (3.11)	4.45 (1.97)	2.21 (2.67)	7.94	0.001	D, O^ns; D > H^***; O, H^ns

p < 0.05; ^** p < 0.01; ^*** p < 0.001.

ABC, Aberrant Behavior Checklist; ARI, Affective Reactivity Index; DMDD, disruptive mood dysregulation disorder; ODD, oppositional defiant disorder; HV, healthy volunteer; ns, no statistically significant differences.

The concurrent validity of these three irritability scales in our sample was tested by their Pearson correlations (r) with CBCL aggressive behavior subscale. ABC-irritability, parent, and self-report ARI scores were all significantly correlated with aggressive behavior on the CBCL. The degree of correlation was high for ABC-irritability (r = 0.84) and parent-report ARI (r = 0.68), and low for the self-report ARI (r = 0.29). In addition, these three irritability scales were all significantly correlated with anxious/depressed and social problems on the CBCL. (Table 4)

Table 4.

Pearson Correlations Between Aberrant Behavior Checklist-Irritability Subscale, Affective Reactivity Index, and Child Behavior Checklist Subscale Scores (n = 97)

			ARI
	ABC-irritability		Parent-report		Self-report
	r	p	r	p	r	p
CBCL
Irritability	0.800	<0.001	0.678	<0.001	0.292	0.004
Aggressive behavior	0.843	<0.001	0.677	<0.001	0.291	0.004
Anxious/depressed	0.570	<0.001	0.434	<0.001	0.294	0.003
Social problems	0.548	<0.001	0.453	<0.001	0.324	0.001

ABC, Aberrant Behavior Checklist; ARI, Affective Reactivity Index; CBCL, Child Behavior Checklist.

Association between irritability and adaptive functions

To take social adjustment as outcomes, the Chinese ABC-irritability subscale score and scores of parent and self-report ARI were all significantly associated with problems with peers. However, self-report ARI scores predicted subjective maladjustment in school attitude and peer relationships among children. For the parent-report ARI, higher scores predicted worse home problems but not problems in school, whereas both ABC-irritability subscale scores and self-report ARI scores were significantly associated with school problems. In our results, irritability was not significantly associated with adaptation problems in academic performance, spare-time activities, and problems with siblings (Table 5).

Table 5.

Association Between Irritability and Social Adjustment Inventory for Children and Adolescent Subscales (n = 97)

	Outcomes
	Linear regression models (beta)
	SAICA-school functioning and spare-time activities
Predictors	School academic	School attitude	School problems	Spare-time activities
ABC-irritability subscale	−0.02	0.20	0.35^**	0.03
ARI-parent	−0.08	0.17	0.24	0.10
ARI-self	−0.10	0.28^*	0.47^**	0.17

	SAICA-peer and family relationships
	Peer relationships	Problems with peers	Siblings relationships	Home problems
ABC-irritability subscale	0.11	0.29^*	0.11	0.25
ARI-parent	0.12	0.28^*	0.05	0.33^*
ARI-self	0.34^*	0.46^**	0.07	0.25

p < 0.00625; ^** p < 0.001.

ABC, Aberrant Behavior Checklist; ARI, Affective Reactivity Index; SAICA, Social Adjustment Inventory for Children and Adolescents.

Discussion

To date, this is the first study to examine the psychometric properties of two Chinese version irritability scales, the ARI and the ABC-irritability subscale, in a clinical sample of children and adolescents in Taiwan. The results demonstrate satisfactory test–retest reliability, good internal consistency, and validity of these two irritability inventories. This suggests that both the ARI and the ABC-irritability subscale may be used to measure irritability among youth with different psychiatric diagnoses. Meanwhile, in line with previously published reports (Deveney et al. 2015), youth with irritability in our sample appeared to be susceptible to concurrent depressed and anxious symptoms, and significantly impaired social adjustments. The findings suggest that these two inventories may also be useful instruments for identifying youths at risk of long-term adverse outcomes related to chronic irritability.

The two Chinese version irritability scales had high internal consistency and scores were stable over time, compatible with the psychometric characteristics of original versions of the ARI and ABC (Aman et al. 1985a; Stringaris et al. 2012a). The results support the clinical conceptualization of DMDD that irritability is a mood, and also support that the severity of irritability can be measured quantitatively. The high stability indicates that significant changes in scores of the ARI and the ABC-irritability subscale can be interpreted as a true difference rather than random intertemporal fluctuations in scale scores. Therefore, these two scales may be reliable measurements for monitoring treatment effects in clinical studies.

We found that the ABC-irritability subscale score was highly correlated with the scores of parent-report ARI. The ABC-irritability scale is composed of items regarding irritability and the consequent aggressive behaviors, whereas the ARI only measures irritability. Although children with irritability may not always also have aggressive behaviors, the high correlation suggests that manifestation of aggression is the common burden for both children with irritability and their parents. The agreement between parent and child ratings on the Chinese version of the ARI was lower than that of the original version (Stringaris et al. 2012a), but was satisfactory according to a meta-analysis on crossinformant agreement between children and parents (Achenbach et al. 1987). In addition, the comparison of item mean between the parent-report and self-report form ARI demonstrated high consistency of ratings from parents and children. The ABC-irritability subscale score was also significantly correlated with the self-report ARI. The correlation between the ratings from parents and participating youth suggests the presence of self-awareness in children and adolescents of their irritability, which was also observable by their parents.

The comparison of these two irritability scale scores among three different diagnostic groups shows that these scales have high correlation with psychopathology. Children with DMDD have the most severe irritability and temper outbursts by DSM-5 diagnostic criteria. Children with ODD also have irritable mood, but they do not remain irritable, and have less frequent and less intensive temper tantrums than those with DMDD. Healthy volunteers do not have irritability beyond the normal range. Based on our results from the two parent-administered inventories, the ABC-irritability subscale and the parent-report ARI, the level of irritability was highest in youths with DMDD compared with those with ODD and healthy volunteers. In addition, irritability in youths with ODD was higher than in healthy volunteers. However, our findings suggest that the self-report ARI was less effective for differentiating these diagnostic entities. According to the results from the self-report ARI, there was no difference in irritability between youths with either DMDD and ODD or ODD and healthy volunteers, although irritability in DMDD was still higher than in healthy volunteers. This may imply that self-awareness of irritability is still limited in this population.

The CBCL-irritability scale, which has been used to measure irritability among adolescents in previous research (Stringaris et al. 2012b), was used in this study to demonstrate good concurrent validity of the Chinese version ARI and ABC-irritability subscale. Moreover, children with higher scores on the ARI and ABC-irritability subscale were found to have more aggressive behaviors, more anxious/depressed symptoms, and worse social problems rated on the CBCL. These findings are consistent with the present literature regarding clinical correlates of youths with severe irritability, including the common co-occurring emotional and behavioral disorders as well as social impairment (Brotman et al. 2006; Copeland et al. 2013; Dougherty et al. 2014). It suggests that early intervention programs targeting irritability might reduce future emotional or behavioral disturbances among children. However, the mechanisms of the overlap between irritability and other psychiatric disorders are still under investigation.

Another approach to establish the convergent validity of these two irritability scales was to explore the association between irritability and social adjustment, which reflected children's psychosocial function. This study's results showed that youths with irritability, both rated by the ARI and the ABC-irritability subscale, had more maladaptive behaviors in school, among peers, and at home. As shown by previous research, children with chronic irritability are prone to experience lower popularity, lower social competence, and impaired relationships with parents and teachers (Copeland et al. 2013; Dougherty et al. 2014). These maladaptations might be associated with aberrant reward and threat processing underlying irritability (Brotman et al. 2017), and the high comorbidity rate between irritability and disruptive behavior disorders (Brotman et al. 2006; Copeland et al. 2013; Dougherty et al. 2014). Our results also demonstrated the crossdomain impairments of severe irritability that require clinical attention and effective management to address these children's irritability and dysfunction.

Several limitations of this study need to be addressed. First, all our subjects were recruited from a university hospital clinic. Hence, possible referral bias should be considered, and further epidemiological studies are needed to validate our results. Second, the sample sizes of different diagnoses with manifestation of irritability were small. Future studies with larger clinical samples should be conducted to explore symptom profiles of irritability in different diagnostic entities. Third, the cross-sectional design could not identify causal relationships between irritability and co-occurring psychopathological problems. Prospective studies are warranted to clarify the predictability of irritable mood, as assessed by the ARI and the ABC-irritability subscale, for predicting long-term psychiatric outcomes and psychosocial functioning among irritable children whose other psychopathologies have been ruled out by means of DSM interview or formal DSM screener.

Conclusions

The results of our study suggest that both the Chinese version of the ARI and the ABC-irritability subscale are reliable and valid instruments for measuring irritability among youths in Chinese population. Irritability among children may be associated with impaired social adaptive functioning. These two inventories could be helpful for rating the severity of irritability and for monitoring treatment effects in both research and clinical settings. Future studies aimed at developing effective intervention programs to manage irritability among youths and to improve their adjustment in all domains are warranted.

Clinical Significance

Our validation study of the Chinese version of the ARI and ABC-irritability subscale provides clinicians with instruments with apparently good potential for assessing irritability in children. In addition, our report revealed that irritability among children may be significantly associated with impaired social adjustment. These two inventories may help professionals working for children's mental health identify the youths at risk of adverse outcomes related to chronic irritability.

Footnotes

Acknowledgment

The authors wish to thank all the study participants who committed their time, and whose responses form the basis of this work.

Disclosures

No competing financial interests exist.

References

Achenbach

: Manual for the Child Behavior Checklist/4–18 and 1991 Profile. Department of Psychiatry, University of Vermont, Burlington, Vermont, 1991.

Achenbach

, McConaughy

, Howell

: Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychol Bull, 101:213–232, 1987.

Aebi

, Plattner

, Metzke

, Bessler

, Steinhausen

: Parent- and self-reported dimensions of oppositionality in youth: Construct validity, concurrent validity, and the prediction of criminal outcomes in adulthood. J Child Psychol Psychiatry, 54:941–949, 2013.

Aman

, Singh

, Stewart

, Field

: Psychometric characteristics of the aberrant behavior checklist. Am J Ment Defic, 89:492–502, 1985a.

Aman

, Singh

, Stewart

, Field

: The aberrant behavior checklist: A behavior rating scale for the assessment of treatment effects. Am J Ment Defic, 89:485–491, 1985b.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association, 2013.

Brotman

, Kircanski

, Stringaris

, Pine

, Leibenluft

: Irritability in youths: A translational model. Am J Psychiatry, 174:520–532, 2017.

Brotman

, Schmajuk

, Rich

, Dickstein

, Guyer

, Costello

, Egger

, Angold

, Pine

, Leibenluft

: Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry, 60:991–997, 2006.

10.

Collishaw

, Maughan

, Natarajan

, Pickles

: Trends in adolescent emotional problems in England: A comparison of two national cohorts twenty years apart. J Child Psychol Psychiatry, 51:885–894, 2010.

11.

Copeland

, Angold

, Costello

, Egger

: Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. Am J Psychiatry, 170:173–179, 2013.

12.

Deveney

, Hommer

, Reeves

, Stringaris

, Hinton

, Haring

, Vidal-Ribas

, Towbin

, Brotman

, Leibenluft

: A prospective study of severe irritability in youths: 2- and 4-year follow-up. Depress Anxiety, 32:364–372, 2015.

13.

Dougherty

, Smith

, Bufferd

, Carlson

, Stringaris

, Leibenluft

, Klein

: DSM-5 disruptive mood dysregulation disorder: Correlates and predictors in young children. Psychol Med, 44:2339–2350, 2014.

14.

Gau

, Shen

, Chou

, Tang

, Chiu

, Gau

: Determinants of adherence to methylphenidate and the impact of poor adherence on maternal and family measures. J Child Adolesc Psychopharmacol, 16:286–297, 2006.

15.

John

, Gammon

, Prusoff

, Warner

: The Social Adjustment Inventory for Children and Adolescents (SAICA): Testing of a new semistructured interview. J Am Acad Child Adolesc Psychiatry, 26:898–911, 1987.

16.

Krieger

, Pheula

, Coelho

, Zeni

, Tramontina

, Zeni

, Rohde

: An open-label trial of risperidone in children and adolescents with severe mood dysregulation. J Child Adolesc Psychopharmacol, 21:237–243, 2011.

17.

Mulraney

, Melvin

, Tonge

: Psychometric properties of the affective reactivity index in Australian adults and adolescents. Psychol Assess, 26:148–155, 2014.

18.

Peterson

, Zhang

, Santa Lucia

, King

, Lewis

: Risk factors for presenting problems in child psychiatric emergencies. J Am Acad Child Adolesc Psychiatry, 35:1162–1173, 1996.

19.

Roberson-Nay

, Leibenluft

, Brotman

, Myers

, Larsson

, Lichtenstein

, Kendler

: Longitudinal stability of genetic and environmental influences on irritability: From childhood to young adulthood. Am J Psychiatry, 172:657–664, 2015.

20.

Stringaris

, Goodman

, Ferdinando

, Razdan

, Muhrer

, Leibenluft

, Brotman

: The Affective Reactivity Index: a concise irritability scale for clinical and research settings. J Child Psychol Psychiatry, 53:1109–1117, 2012a.

21.

Stringaris

, Zavos

, Leibenluft

, Maughan

, Eley

: Adolescent irritability: Phenotypic associations and genetic links with depressed mood. Am J Psychiatry, 169:47–54, 2012b.

22.

Vidal-Ribas

, Brotman

, Valdivieso

, Leibenluft

, Stringaris

: The status of irritability in psychiatry: A conceptual and quantitative review. J Am Acad Child Adolesc Psychiatry, 55:556–570, 2016.

23.

Wechsler

: Wechsler Intelligence Scale for Children-Fourth Edition-Chinese Version. The Chinese Behavioral Science Coporation, Taipei, Taiwan, 2007.

24.

Wiggins

, Mitchell

, Stringaris

, Leibenluft

: Developmental trajectories of irritability and bidirectional associations with maternal depression. J Am Acad Child Adolesc Psychiatry, 53:1191–1205, 1205.e1191–1194, 2014.