Assessment of irritability in school-aged children by pediatric,family practice,and psychiatric providers

Abstract

Background:

Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication.

Objective:

Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability.

Methods:

A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed.

Results:

In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups.

Conclusion:

This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

Keywords

Bipolar child and adolescent psychiatry irritability primary care school-aged children

Background

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of mental disorders with criteria designed to facilitate more reliable diagnoses. Over the past 60 years, successive editions of the manual have become a standard reference for clinical practice in the mental health field.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) released in 2013 uses a more dimensional approach, as the rigid categorical system in the previous edition does not capture clinical experience or important scientific observations (Krueger, Hopwood, Wright, & Markon, 2014). The DSM classification is correlated to the World Health Organization’s International Classification of Diseases (ICD), the official coding system in the United States.

While DSM serves as an authoritative resource for psychiatric (PS) providers, its use by primary care providers for children appears limited. A literature search regarding use of DSM in primary care and pediatrics suggested that these providers use screening questionnaires, such as Modified Checklist for Autism (M-CHAT; Robins & Dumont-Mathieu, 2006), which include components of DSM criteria when they want a more thorough assessment.

Primary care providers (i.e. family medicine (FM) and pediatrics (P)) often make the first mental health diagnoses (Anderson, Chen, Perrin, & Van Cleave, 2015) warranting treatment. Preliminary conversations with six primary care colleagues suggested that there was limited use of DSM in the real time in clinics. During these conversations, there was an expressed interest in the increasing importance of how they might accurately assess commonly presenting behavioral symptoms such as irritability.

Disruptive Mood Dysregulation Disorder (DMDD) is a new addition to the depressive disorder category in DSM-5 (Rao, 2014). This diagnosis evolved from “Severe Mood Dysregulation SMD” (Leibenluft, 2011) and “Temper Dysregulation Disorder with Dysphoria” during the development phase of DSM-5 (Stringaris, 2011). DMDD was intended to capture temper outbursts and irritability in children beyond what may be considered normal. Early differentiation of normal versus abnormal irritability is important, since diagnosis of bipolar disorder and subsequent treatment with antipsychotic mood stabilizing medication has increased dramatically in recent years (Krieger & Stringaris, 2013; Leibenluft, 2011).

With this new diagnosis, a more thoughtful and dimensional approach has been suggested for providers who diagnose and treat irritable mood behaviors versus bipolar disorder in children (Krieger, Leibenluft, Stringaris, & Polanczyk, 2013; Margulies, Weintraub, Basile, Grover, & Carlson, 2012). In addition, due to growing concerns about violent behaviors which have been associated with irritability (Hsu, Huang, & Tu, 2014), recognition of irritable mood and episodes of rage is critical for primary care providers (Hameed & Dellasega, 2016). However, accurate diagnosis is challenging, as DMDD can co-occur with common psychiatric disorders (Copeland, Angold, Costello, & Egger, 2013) and may be treated similarly to depression, oppositionality, defiance, inattention, hyperactivity, and impulsivity. Correctly identifying irritability, which requires monitoring alone, versus that which requires treatment with behavioral management or medication, and/or referral to a specialist, is a critical consideration.

Objective

Accurate assessment of irritability is a necessary first step in establishing a correct diagnosis and treatment plan. Limited awareness about the parameters of normal developmental irritability can lead clinicians to consider a mental health diagnosis when in fact, less invasive behavioral methods can be used to address the situation. Once we understand the baseline assessment strategies of clinicians from different specialties, we may then proceed to further research on a specific diagnosis of DMDD.

Minimizing misdiagnosis and treatment of bipolar disorders in pediatric patients as well as unnecessary exposure to mood stabilizers, including anti-epileptic and anti-psychotic medications (Roy, Lopes, & Klein, 2014) is important, as many of these drugs have serious side effects. In addition, it is critical to identify and manage aggressive and violent behavior in schools and communities before it becomes explosive.

Objective

The objective of this study was to determine whether clinician characteristics, such as specialization and demographics, influence their assessment and treatment of irritability in school-aged children.

The research questions were as follows:

Are there significant differences in how psychiatric specialists and non-specialists assess irritability in the clinical setting?

What themes related to assessment of irritability emerge from providers working with children in the outpatient setting?

To answer these preliminary questions, we used qualitative interviews with three groups of providers, with the intent of exploring their clinical approaches to assessing and managing irritability. Qualitative research was appropriate because little scholarship is available in this area and the study results would generate hypotheses for future study.

Methods

Preliminary work

Six informal 15-minute conversations about the new DMDD diagnosis in DSM-5 were conducted with colleagues who were PS, P, and FM providers. These suggested that there was limited awareness about changes to DSM-5 related to DMDD, but had interest in learning more. Furthermore, these conversations suggested a lack of confidence in the ability of primary care providers to differentiate DMDD from bipolar and other disorders related to irritability in children (Deveney et al., 2015; Leibenluft, 2011).

In keeping with the tenets of qualitative methods, we then returned to the literature to perform a concept analysis that would help us better understand irritability as a construct and develop more specific interview questions (Hameed & Dellasega, 2016). This analysis provided a richer understanding of potential challenges to the assessment of irritability (including other conditions which could present as irritability) as well as clarity on differentiating the DSM diagnoses of DMDD and bipolar disorder.

Based on the conceptual analysis, we then planned a study that would interview providers whose caseload included school-aged children with a complaint related to irritability. We developed an interview frame relevant to FM, P, and PS providers, including criteria used in assessment, resources consulted, confidence in treatment, and typical scenarios.

Sample

After obtaining Institutional Review Board (IRB) approval, we contacted key personnel in the three departments regarding access to their providers, and sent recruitment letter and flier via email for circulation. We also attended their departmental meetings to describe the study and invite participation. Eligibility included any primary/specialty care provider who treated school-aged children and was willing to be interviewed. For the purposes of this study, school age was defined as ages 6–17 years.

A total of 18 providers volunteered to participate, with 17 completing interviews. One volunteer was not able to participate in an interview due to time constraints.

Procedures

A first-year medical student functioned as the study interviewer and co-investigator. To avoid introducing bias from multiple interviewers (Klenke, 2016), only one interviewer was used to conduct interviews. Providers who responded to our call for participation were contacted by the interviewer, who set up a time for the interview and obtained informed consent.

To prepare the interviewer, 4 hours of training on qualitative research and interviewing techniques was provided by an expert researcher. The interviewer then completed two separate pilot interviews under the supervision of the principal investigators and feedback was provided. The principal investigators also accompanied the interviewers on the initial interviews until there was agreement that the required level of proficiency was achieved. Periodic audits of transcripts were conducted by the investigators to ensure fidelity to the study purpose and reliability of the questions asked from interview-to-interview.

All interviews were tape-recorded and lasted approximately 1 hour. Interviews were structured for the participants’ convenience in a private and secure place, such as the participant’s office. A modest gift certificate was given to those who participated.

In order to preserve confidentiality, the interviewer assigned each participant interviewee an identification number at the time of obtaining consent. The participants from FM were identified as FM-1, FM-2, and FM-3; Pediatric participants as P-1, P-2, P-3, Psychiatry providers as PS-1, PS-2, PS-3, and so on. The identifier was used for tracking purposes on all data obtained from participants.

Upon completion of the interview and data collection, each participant’s responses were placed on separate files. The taped interviews were transcribed verbatim by the interviewer within 1 week of being recorded. During transcription, interviews were reviewed and any possible identifying information that was inadvertently included was redacted. The investigators maintained weekly contact to determine the study progress and the degree to which saturation had been reached.

Instruments

Each interview was preceded by a collection of demographic data including age, gender, years of training, specialty, percentage of current caseload with irritability/behavior problems, previous experience working with youth with mental illness, attendance at conferences or workshops on mental health issues in general or irritability or DMDD specifically, general confidence in ability to perform mental health screening, knowledge of DSM, and awareness of changes specific to addition of DMDD in the fifth edition of the manual.

An interview frame was developed based on important concepts from the clinical and research literature along with input and review by experts in child and adolescent psychiatry and pediatrics. Table 1 lists the questions and potential probes.

Table 1.

Questions asked in each interview to assess irritability.

1	First, can you tell me how you define irritability in school-aged children?
2	In your clinic, is it more likely that a child will come in with a chief complaint of irritability or that you would observe irritable behaviors during the exam?
3	How do you evaluate a child’s irritability?
4	Could you describe a memorable patient of yours who had irritability?
5	How would you differentiate between normal versus abnormal comorbid irritability?
6	If you were unsure of whether a child’s irritability was normal or abnormal, what would you do next?
7	Is there anything else you feel is important for us to know about assessing irritability in school-aged children?

Appropriate probes were used as needed to promote elaboration during the interview. These included determining what type of information about irritability was collected and from whom (patient, parents, or school) and what assessment instruments/scales/manuals or other resources were used.

Analysis

Each of the investigators and the research analyst (RA) independently reviewed the transcribed interviews until there was consensus on saturation. Since qualitative research, especially with homogeneous groups, may utilize smaller samples, when no new information or themes occurred in subsequent interviews, saturation was achieved after five interviews from each specialty were completed, providing a representative review of within and across provider backgrounds (Boddy, 2016).

One interview was eliminated because the team agreed that the interviewee was not focused on the questions and provided answers that did not advance an understanding of irritability. A final sample of five FM, five P, and six PS providers was obtained.

After achieving saturation and cleaning of transcripts, content analysis of data as described by Bengtsson (2016) was conducted as detailed below:

A line-by-line reading was conducted to identify patterns within PS, P, and FM transcripts.

Grouping of themes was accomplished through axial coding.

Core concepts that repeated within and across interviews were identified.

The team identified categories that captured key themes.

The group returned to the individual interviews and tested the validity of the categories.

An analysis of categories across specialties was undertaken to compare and contrast.

The demographic and other numerical data were entered into an SPSS database and analyzed using frequency distributions and descriptive analysis. Although the sample size was small, results between the three groups were compared for significant differences using t-test and correlational procedures.

Results

Quantitative

Gender was distributed as 47% male and 53% female across the three groups, there was no significant difference between the groups (Table 2).

Table 2.

Comparison of gender between the participants across all groups.

	Gender	Frequency	Percentage	Valid percentage	Cumulative percentage
Valid	Male	8	44.4	47.1	47.1
	Female	9	50.0	52.9	100.0
	Total	17	94.4	100.0
Missing	System	1	5.6
Total		18	100.0

As expected, the difference in percentage of patients seen with irritability was statistically significant among the groups (F = 123.2, p < .0011), with PS providers having increased exposure to evaluation of patients with irritability (p < .0011). Not surprisingly, significant difference was also reported by PS about increased knowledge of DSM (F = 8.065, p < .011) and more confidence with evaluating irritability (F = 6.094, p < .01; Table 3).

Table 3.

One-way ANOVA to assess demographic data between FM, P, and PS providers.

	Sum of squares	df	Mean squares	F	Sig.
Age
Between groups	137.025	2	68.513	0.741	.494
Within groups	1294.033	14	92.431
Total	1431.059	16
Years of training
Between groups	20.663	2	10.331	1.406	.278
Within groups	102.867	14	7.348
Total	123.529	16
Percent irritable
Between groups	21,130.937	2	10,565.469	123.260	.000
Within groups	1200.033	14	85.717
Total	22,330.971	16
Experience with MII
Between groups	2.784	2	1.392	14.618	.000
Within groups	1.333	14	0.095
Total	4.118	16

ANOVA: analysis of variance; FM: family medicine; P: pediatrics; PS: psychiatric; df: degrees of freedom; MII: youth with mental illness.

Slightly more than half (59%) of participants had previously worked with mental health issues, with PS providers reporting significantly higher numbers (f = 14.61, p < .0011). Continued medical education (CME) specific to irritability was low across all groups. To further assess whether differences might appear between P and FM (primary care) and PS (specialty care), the first two groups were merged and appropriate statistical tests (t-test and correlation) rerun, which did not reveal different results from those already reported.

Qualitative analysis

Theme #1: Gold standard

All groups agreed that there is no “gold standard” definition of irritability in school-aged children. When asked if there was a gold standard for defining irritability, some of the responses were as follows:

FM-1:

No, not that I’m aware of.

PS-1:

I think people pay more attention to the construct particularly people who are full time in mental health but . . . unless you focus them over a specific meaning I think a lot of people would still just go to aggression when you say the word irritability.

Similarly PS, P, and FM agreed that there is a wide spectrum of issues presenting with irritable behavior. PS considered irritability as a cross-domain construct and similar to pain. As PS-1 said,

I don’t think I would have paid as much attention to differentiating it from some other constructs it’s kind of the mental health equivalent to pain, it’s a very broad construct.

Theme #2: Variable evaluation

When asked how they evaluate irritability, an FM participant said,

FM-3:

I guess initially being open to the likelihood it exists and I would say much like depression or anxiety, some irritability is probably very normative and so much like you know the person who is depressed appropriately after a significant loss in their life or death that might otherwise not become something pathologic and I think you can have pathologic irritability.

It was interesting to note that P providers noted developmental aspects of irritability in clinical presentation, describing the use of comparison to peers and siblings as well as severity of symptom when referral was prompted by teacher and behaviors directly under observation during visit. They also evaluated externalizing versus internalizing behaviors and stressed the importance of collateral information:

P-1 noted:

It’s often identified by the teachers who then ask the parents to come into our office to probe a little further. If I see behaviors though in preschool age I usually bring it up to the parents, often times it’s not until they are in a school setting where someone actually recognizes what’s going on.

FM participants noted the clinical presentation in the context of functional impairment identified as behavioral issue by clinician or reported by parents, teachers and occasionally by the older patient themselves. As FM-1 stated,

Abnormal definitely if they’re not functioning well in either the family unit or the school environment or a child’s very unhappy with their self and the way they are functioning or not functioning.

FM and P participants noted some correlation between irritability and other diagnostic entities, but PS noted irritability as a component of numerous diagnoses, as well as connected to lack of sleep and a possible adverse effect of medications. All groups stressed the importance of time constraints as a barrier to complete assessment of irritability in a school-aged child.

Theme #3: A clinical example

When asked to describe a memorable patient with irritability, the FM participants had a much more diverse age range of 6–17 years and provided hypothetical examples. The P and PS participants mostly discussed patients in the younger school age range of 6–12 years.

Theme #4: Important informants

FM participants mainly used parental and teacher input of patient behavior, with some weight on child report. Commenting on this, FM-1 said,

I think they’re both important I don’t know that I would weigh one over the other cause the child has to spend a significant amount of time in both situations. So I think both are important I don’t think I would weigh one over the other.

FM participants said they considered academic and social pressures and used depression scales such as PHQ-9 (Patient Health Questionnaire-9).

Theme #5: Collateral resources

P participants reported consideration of medical causes, abuse and family history, psychoeducational assessments, collateral information, direct observation, and use of rating scales for depression (PHQ), anxiety (SCARED), and externalizing behaviors (Vanderbilt):

P-1:

If they’re having learning issues at school or like problems getting along with other kids at school I usually have the patients request psycho-educational testing.

P-2:

In adolescence we do PHQ screening at every well child visit so looking for depressive symptoms if a parent expresses concerns to me about that struck me as anxiety related symptoms I use the SCARED screening tool and then at every well child visit I like to ask questions about family dynamics.

P interviewees considered using longer return visits to address specific issues and complete the evaluation.

DSM was not used by most FM and P providers but they instead relied on UpToDate (Fox & Moawad, 2003), a web-based clinical database. Both groups felt comfortable referring school-aged children with irritability to mental health services.

PS participants discussed much more specific details of assessment including history, collateral information, rating scales, physiological processes, medication adverse effects, and DSM differential diagnoses/comorbidities. As noted by PS-5,

We are also going to look at every comorbid condition because irritability can present in any of the conditions, we check that either they have the ADHD symptoms because irritability can be part of the ADHD, ODD, or mood symptoms, so irritability itself is not the diagnoses . . . if the irritability is just related to the ADHD, you treat the ADHD, and then reevaluate if the irritability is still there or not, do they need other intervention or not?

As there are no rating scales for irritability, PS-1 suggested,

I think we don’t have any instruments specifically about irritability, mostly we send them ADHD or ODD and then some of the components of those scales which the teacher reports like how often, like very often versus seldom or never a problem so we can (work) through other rating scales specifically for ADHD or ODD, not particularly for the irritability per say.

All groups were comfortable with identifying and managing “red flags” or safety concerns.

Theme #6: Treatment options

In terms of treatment, it was interesting to note that P and FM focused on referring to mental health when irritability became complex. FM interviewees described being comfortable primarily with antidepressants. Some P participants were comfortable with antidepressants, anxiolytics, mood stabilizers, and attention deficit hyperactivity disorder (ADHD) medications.

In contrast, the PS informants while comfortable with medications, relied more on behavior therapy, psychosocial and family interventions. As PS-1 stated,

I certainly have had kids who don’t respond to the treatment algorithm like I think that they should and then it’s helpful to have a colleague’s opinion on that and I will refer a lot of families for behavioral therapy. I do a little bit of it myself but I try to get everyone connected to a behavioral therapist who has any difficulty with persistent irritability or aggression.

One of the PS interviewees never used medications, but instead referred to therapists who could work with the child and the family.

Limitations

This study was limited by recruitment of participants, all of whom were clinicians from one institution, resulting in a sample size that permitted saturation but not generalization. Additional interviews conducted more broadly, in other geographical areas of the country and in other institutions may yield different results.

The student who conducted the interviews used a standardized interview frame to ensure that there was consistency between each interview, being a novice qualitative researcher. Although the frame was followed as closely as possible, occasional clarification of questions was requested by the participants, and the interviewer’s responses to these questions were not scripted. This may have led to a variation in participant’s responses, not controlled for by a set script.

We used a broad definition of “school aged” rather than identifying a much younger age range. As none of our participants described irritabilities specific to the teen years, such as bullying, romantic relationships, or substance abuse, we conclude that irritability is considered a behavior associated more strongly with the younger years.

Discussion

This preliminary exploration of “irritability” raised some important questions about the assessment and treatment of children in different clinical settings. First, as there is no gold standard definition of irritability, how do we begin to understand this construct? Our earlier work explored the definition of irritability and a review of the literature suggests this concept is ill defined (Hameed & Dellasega, 2016). DSM-5 does not define this symptom, but we have enlisted DSM diagnoses that commonly present with irritability, differentiated by the age of presentation and typical features (Hameed & Dellasega, 2016). We have discussed one approach as use of terms such as “getting angry, being easily annoyed, losing temper or having tantrums,” while also reviewing a more in-depth method and description in the literature (Judd, Schettler, Coryell, Akiskal, & Fiedorowicz, 2013; Keel, 2014; Mayes et al., 2015; Tseng et al., 2015).

Second, how does “expertise,” that is, caseload mix, knowledge of DSM, or continued medical education influence a clinician’s confidence in his or her ability to perform mental health screening or assessment? Third, would there be value in an educational program about irritability, or would knowledge of DSM improve the comfort and confidence of primary care providers in assessing irritability? Overarching these questions was the need to understand how primary care practitioners versus psychiatrists viewed their role in this important area of medicine.

PS providers had clinically significant caseloads with irritability and high knowledge of DSM, as expected. This may have contributed to their higher degree of confidence in assessing irritability. At the same time, PS participants, like FM and P, had little continuing education on irritability. This suggested that continuing education did not necessarily increase the comfort with assessing irritability as much as familiarity with DSM and clinical practice. Review of the literature suggested improved confidence with continuing medical education (Byszewski et al., 2003), but there was no comparison between clinical practice and continuing education. We believe continued education, aligned with clinical practice, may improve confidence. As a first step toward providing information specific to irritability, a brochure with easy-to-access information on assessing and treating irritability in school-aged children was synthesized from our results and is being piloted in the clinical setting.

Clearly, the identified “expertise” of psychiatry contributed to the process of evaluating children with irritability. It was noted that by the time a child reached the psychiatry clinic, it was already established that a problem existed:

PS-1:

The predominant reasons people come to see me for are oppositional arguing behaviors, irritability, which most often manifests with a persistent negative mood and frequent temper outbursts, and then probably secondarily would be attention issues causing academic distress. But irritability and aggression and oppositionality are the three most common reasons that drive kids into mental health treatment.

Surprisingly, although primary care providers often referred children to psychiatry for more complex psychopharmacology, the PS participants tended not to rely primarily on medications. This may be due to familiarity of the PS providers with available non-pharmacological treatment modalities, accessibility of resources, and more time with the patient. PS-1 commented on the ability of primary care providers to care for these patients rather than referring them on, by saying,

I think most primary care doctors should get to the point where they are comfortable trying to treat commonly co-occurring disorders like ADHD or anxiety and seeing if that helps irritability and also identifying irritability or aggression that’s developmentally abnormal enough that’s worth meriting to a specialist. If the first pass treatment for the ADHD/anxiety doesn’t work and the irritability persists then I would definitely recommend referring to a specialist.

This raises a question about the available resources in a primary care setting. As previously mentioned, UpToDate (Fox & Moawad, 2003), a widely used online resource and mobile app that offers current evidence-based medical information and clinical decision support, was the single most used resource by many FM and P participants in this study. However, this resource does not provide much information about the various nuances of irritability participants described in their responses, nor does it offer a comprehensive approach to assessing or treating this symptom. One of the FM providers, in response to use of any resources, stated,

FM-5:

Yeah I’ve looked at UpToDate and like um MedScape. I can’t say it’s been particularly useful for this type of or irritability or this type of issue . . .

Another option to consider is use of rating scales such as Vanderbilt ADHD Diagnostic Rating Scales, Conners, PHQ-9, Generalized Anxiety Disorder-7 (GAD-7), and Children’s Depression Inventory (CDI), which are commonly available in the primary care setting and contain questions on irritability items that may be useful in the assessment (Hameed & Dellasega, 2016). Some examples of items addressing irritability are noted in Table 4.

Table 4.

Irritability items on rating scales used in primary care.

Rating scale	Item number
Vanderbilt (parent)	20. Loses temper 24. Is touchy or easily annoyed by others25. Is angry or resentful
Conners (3: parent)	14. Loses temper 40. Demands must be met immediately—easily frustrated 48. Is angry and resentful73. Is irritable and easily annoyed by others81. Temper outbursts 100. Becomes irritable when anxious
PHQ-9	1. Feeling down, depressed, irritable, or hopeless?
GAD-7	6. Becoming easily annoyed or irritable
CDI (2 self-report)	Item 7I feel cranky all the timeI feel cranky many timesI am almost never cranky

PHQ: Patient Health Questionnaire; GAD: Generalized Anxiety Disorder; CDI: Children’s Depression Inventory.

However, due to limited number of PS providers in the community setting (Kim & American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs, 2003), FM and P providers may have limited options for obtaining specific information or making referrals. For the safety of children, their peers, and the adults who care for them, there is a need for prompt services, appropriate intervention, and efficient use of resources. This has led to development of hybrid programs, such as telephonic psychiatric consult services, for primary care providers (Pidano et al., 2016) in some states, which will hopefully offset such issues.

Another broader question is how we should approach a cross-domain symptom such as irritability. Is a symptom-based approach more appropriate than attempting to compartmentalize the associated syndrome into a diagnostic category? As more studies become available questioning the validity of some disorders with irritability as an underlying symptom (Baweja, Mayes, Hameed, & Waxmonsky, 2016), this question may be answered. Further research is clearly necessary to guide accurate and effective assessment and treatment methods, especially with increasing rates of irritable and aggressive students who act out in the school setting. That discussion, albeit an interesting one, is beyond the scope of this article.

Conclusion

The interviews in this study suggest average confidence in the ability to perform mental health assessment among primary care participants, who often are the first line of care for school-aged children with irritability. Our data suggest that clinical experience and user-friendly information from DSM rather than continued education may improve comfort with assessing irritability by primary care providers.

All the groups agreed that the concept of irritability has evolved with more attention to this symptom in school-aged children and saw connections with developmental level, environment, physical, and emotional problems and consequent behaviors that could lead to impairment in various functional domains, but treatment approaches varied. The two primary care groups were likely to depend on basic medication treatment (antidepressants) and referral for more complicated situations, while PS providers looked to therapy for both patient and family. The PS interviewees suggested a need for better understanding of the available psychosocial services at the primary care level, so these could be considered prior to referral to mental health.

This study highlights the increasing importance of integration and collaboration between primary care and subspecialties in accurate assessment and subsequent treatment of school-aged children with irritability. Additional research is required to establish how to assess irritability in the primary care setting and better use of the range of options in treatment. Given a limited number of mental health specialists, more support at the primary care level can lead to improved outcomes for children, avoiding progression to violent behavior and/or inappropriate diagnoses and medications.

Footnotes

Authors’ Note

Anna Scandinaro is now affiliated with Department of Internal Medicine, Cleveland Clinic Foundation, USA.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anna Scandinaro

Author biographies

Usman Hameed, MD, is a Child and Adolescent Psychiatrist and an Assistant Professor of Psychiatry at the Penn State College of Medicine. His area of interest include internalizing and externalizing behavioral issues in the pediatric population.

Cheryl Dellasega is a Professor of Humanities in the Penn State College of Medicine as well as a nurse practitioner and PhD. She has studied mental health issues across the lifespan using both qualitative and quantitative strategies. Her work has been published and presented to both national and international audiences.

Anna Scandinaro, MD, is currently in her first year of Internal Medicine residency at the Cleveland Clinic Foundation. She attended Penn State College of Medicine and receieved her medical degree in 2019. Her areas of interest extend across psychiatry and internal medicine.

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