Irritability in Childhood May Point to Teens At High Risk for Suicide

Youth who were highly irritable during childhood were more likely to report suicidal ideation and/or attempt suicide as teenagers, according to a study published in JAMA Psychiatry in May.

The study found that children rated as having high irritability and high depressive/anxious mood were more than twice as likely to be suicidal in adolescence, compared with those with neither irritability nor depressive/anxious mood. Even children with moderate yet stable levels of irritability and low depressive/anxious mood were found to be at an elevated risk of suicide during adolescence.

“Evidence linking childhood irritability and adolescent suicidality was very limited,” study author Massimiliano Orri, Ph.D., of the Douglas Mental Health University Institute in Montreal, told Psychiatric News via email. “This study brings new evidence supporting this association. It points to the importance for clinicians to evaluate the suicidal risk of children presenting with high irritability and depressed/anxious mood.”

Orri and colleagues pulled data from a longitudinal study for 1,430 participants in Quebec who were followed from infancy through age 17. School teachers evaluated the behavior of the children five times during elementary school years, rating how often children showed symptoms of depressive/anxious mood, such as crying and worrying, and of irritability, such as temper tantrums and aggressive reactions when teased or something was taken away. Later, the same youth were asked at ages 13, 15, and 17 about whether they had ever seriously thought about attempting suicide and, if so, how many attempts they had made.

Overall, 172 participants reported suicidality (12 percent), with about half of those reporting serious suicidal ideation and half reporting suicide attempts. For participants with high irritability and high depressive/anxious mood, 16 percent reported suicidality.

Orri said he found it surprising that the patterns of irritability and depressive/anxious mood that teachers reported in some children remained stable across their childhood. “Children with the highest levels of symptoms at 6 years of age also had the highest levels of symptoms at 12 years of age,” explained Orri. “If these findings are replicated, they may help to further clarify the role of early childhood symptoms on later suicidality.”

“The study breathes life into the philosophy I have when I teach parents, families, and teachers about the warning signs and triggers for suicidality,” said Judith F. Joseph, M.D., M.B.A., who reviewed the study at the request of Psychiatric News. Joseph is a private practitioner in New York City and a clinical assistant professor in the Department of Child and Adolescent Psychiatry at NYU Langone Medical Center. “Children and parents express depression and suicidality so much differently from adults. Most children and teens are not going to use or even relate to the term ‘depression.’ Instead, most teenagers say ‘Yeah, I snapped at my mom’ or that they’ve been cranky or grumpy. Even my most depressed teen patients will say ‘Depression? What’s that? That’s not me.’”

What’s the solution? Adults need to use terms to which children and teens can relate and learn to speak their language, said Joseph, who is also a principal investigator at Manhattan Behavioral Medicine PLLC. “These days kids are using social media and Snapchat to express themselves. So if we see a child or teen posting violent or aggressive memes, we have to be attuned to that, to the way they express their depression.”

The study found irritability in girls led more frequently to suicidality than it did for boys. Among those with high irritability and depressive/anxious mood, 1 in 10 boys reported suicidal ideation or attempt in adolescence. Among girls with the same symptoms, the incidence increased to 1 in 3 reporting suicidal ideation or attempt as adolescents.

“A particularly important finding, that needs further investigation, is the heightened suicidality risk for girls who are highly irritable and have a highly depressive/anxious mood in childhood,” Orri said. “Despite the fact that having high irritability and depressive/anxious mood in childhood is more common for boys, the risk for suicidality associated with these symptoms may be more important for girls.”

Joseph said she was not surprised at the finding. “When a female, especially in our country, displays more aggression, it is frowned upon. Girls are taught to be ‘ladies.’ When a girl is breaking that norm, it shows more impulsivity and it triggers the alarm bells. It shows something is happening on a deeper level,” she cautioned.

Despite the study findings, Joseph does not recommend treating children and adolescents for irritability thesame as for depression. “You can’t go treating an irritable child as though thechild has depression because there could be another underlying mental disorder causing the behavior, such as bipolar disorder, for which irritability is a hallmark.” When working with a new patient, Joseph said she does a thorough family history to determine risk of heritable mental disorders and works with a youth’s teacher, pediatrician, and family to get a full picture of the patient.

“Many childhood mental conditions tend to go hand in hand; for example, children with autism also have high anxiety, and teens with depression have higher rates of suicidality and substance abuse,” she said. The complexity of diagnosing youth is one reason why more child and adolescent psychiatrists are needed, she said, “and why we need to better train teachers to detect the warning signs of mental health problems and train pediatricians to help meet these needs.”

Joseph V. Penn, M.D., a former chair of APA’s Council on Children, Adolescents, and Their Families, said additional studies of children with high irritability, depressive/anxious mood, and/or suicidality are needed to determine the long-term risk of mental illness in these youth and how best to treat them. ■