I would recommend the following papers:

(1) Am J Psychiatry. 2011 Feb;168(2):129-42. doi: 10.1176/appi.ajp.2010.10050766. Epub 2010 Dec 1. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Leibenluft E.

(2) Am J Psychiatry. 2012 Jan;169(1):47-54. doi: 10.1176/appi.ajp.2011.10101549. Epub 2011 Oct 31. Adolescent irritability: phenotypic associations and genetic links with depressed mood. Stringaris A, Zavos H, Leibenluft E, Maughan B, Eley TC.

(3) Am J Psychiatry. 2009 Sep;166(9):1048-54. doi: 10.1176/appi.ajp.2009.08121849. Epub 2009 Jul 1. Adult outcomes of youth irritability: a 20-year prospective community-based study. Stringaris A, Cohen P, Pine DS, Leibenluft E.

(4) J Child Psychol Psychiatry. 2009 Mar;50(3):216-23. doi: 10.1111/j.1469-7610.2008.01989.x. Epub 2008 Oct 23. Three dimensions of oppositionality in youth. Stringaris A, Goodman R.

(5) J Am Acad Child Adolesc Psychiatry. 2013 Aug;52(8):831-40. doi: 10.1016/j.jaac.2013.05.017. Epub 2013 Jul 3. Irritable mood as a symptom of depression in youth: prevalence, developmental, and clinical correlates in the great smoky mountains study. Stringaris A, Maughan B, Copeland WS, Costello EJ, Angold A.

Depression Research and Treatment

Volume 2011 (2011), Article ID 126895, 9 pages

http://dx.doi.org/10.1155/2011/126895Research ArticleClinical and Physiological Correlates of Irritability in Depression: Results from the Netherlands Study of Depression and AnxietyFloor E. A. Verhoeven,1 Linda Booij,2,3 Nic J. A. Van der Wee,4 Brenda W. H. J. Penninx,4,5,6 and A. J. Willem Van der Does1,4

http://www.hindawi.com/journals/drt/2011/126895/

They used only one item, but this is adult population.

There is no specific question in KIDI SADS.

The last item on Maria Kovacz CDI may be seen as correlate of irritability.

Or some other depression scale...

Hi,

Being in the USA, I'm not especially familiar with other countries research on this topic. I do, though, agree with Mr. Salum with his listing of various articles by Ellen Leibenluft, et. al. Dr. Leibenluft is with the National Institute of Mental Health and is renowned for her work in child/adolescent mood conditions. Several years ago she published with her colleague, Gabrielle Carlson, M.D. of Stony Brook New York, papers that developed the thesis for Severe Mood Dysregulation (SMD) that address the issue of irritability square on. That research led into talk about Temper Dusregulation DIsorder (TDD) and then Disruptive Mood Dysregulation Disorder (DMDD) found in the DSM 5.

I for one am not happy (as are many others) about how TDD, which morphed into DMDD, evolved as it is felt it does not adequately address Early Onset Bipolar Disorder as well as the vast array of early onset mood states. For that concern, I direct you to the work of Dr. Dimitri Papolos regarding his Fear of Harm (FOH) phenotype of Early Onset (Juvenile) BiPolar Disorder. His writings on that are readily available on his website: www.jbrf.org.

While irritability is surely a sign post for depression in youth, there is much more to the issue than merely as an indicator for depression as you will glean from the suggested resources. That is especially true with "chronic, continual and pervasive irritability."

Please report back with any additional thoughts or concerns. Thank You.

I am interested in this comment: While irritability is surely a sign post for depression in youth, there is much more to the issue than merely as an indicator for depression as you will glean from the suggested resources. That is especially true with "chronic, continual and pervasive irritability."

Can irritability not be considered a trait of character?

Dear Ms. Smith,

You raise an interesting point re: irritability as a character trait. I suppose if one considers the literature on Temperament (traits and styles) there could surely be a trait "resembling" or an indicator of, irritability although I don' t sense that that is the context about which this discussion revolves. Rather that irritability in this context is more the pathological type rather than one of temperament. That being said, I suppose the discussion could address how one tells the difference between an irritable character trait vis a vis irritability that indicates pathology. Any thoughts on that premise?

One surely need to meassure some total "score of depression" , consider some cut off score as significant and then look irritability in it in comparision with group with no significant total score of depression.

That sounds very commonsensical. But it seems to me that there is too much room for confounding factors here.

I also wonder about the 'value' of irritability. It may well be considered in certain circumstances as pathological, but even within such a context it might serve as a valuable messenger of some sort and serve a positive function rather than a negative one.

I only throw these ideas in because I find the concept of measuring features such as these highly problematic.

"Irritability" has always been viewed as a symptom of depression, and adult who had high irritability were called "agitated" depression. Irritability is derived from infant temerapent research, see Rothbart (Mary). Considered neuological in origin, irritable babies spend much more time crying in distress than non-irritable babies. Some longitudinal research shows that babies high in irritability, turn into preschoolers who spend more time fighting than playing. Some of the longitudal work in New Zealand and other well-documented, have identified being "terpreamental" or "neurotic," at greater lifetime risk for depression.

Mark: So are irritable babies considered to be 'born that way' by temperament researchers, if irritability is neurological in origin? Whether it leads to neurotic, and ultimately depressive, characteristics must surely depend on how the irritability is greeted....?

Right on, Isobel. Yes, part of irritability is assumed to be biological, but the intensity of expression, and later, the child's ability to cope with it, are definitely influenced by many different aspects of the environment from diet all the way to maternal atrachment.

So given this complex picture, which many professionals in the field agree on, how might we best understand how the DSM defines and considers irritability as a signal of depression, in adolescents or anyone else, I wonder?

And how would that feed into ways considered appropriate to 'treat' it?

How has the DSM developed its understanding of irritability over the years, and how could anyone track such a development?

Thanks, everyone, for very helpful contributions! To explain the context of my question - I'm working on a large-scale clinical trail, looking at the treatment of moderate/severe adolescent depression. As part of the study we're doing semi-structured (qualitative) interviews with the young people (and parents) before and after treatment. We're currently working on our analysis of the baseline interviews, with a particular focus on young peoples' experience of depression (and how they understand it). What is very striking is the amount of anger that the young people describe - including real problems with controlling anger against others (shouting, smashing chairs, attacking teachers) as well as self. This has been such a striking feature of the interviews (and also found in previous, smaller qualitative studies) that we have become curious about the diagnostic term of 'irritability' (not 'anger') and - as Isabel's last post mentions - the issue of how DSM's understanding of this diagnostic criteria developed... (For which some of the references given above have already been very helpful)...

well this is an interesting topic. I am clinician with interest in research and I can confirm my, personal, strong experience with this irritability/anger issue in C&A population. In practical sense, at least in my country, it might be source of nondesirable outcomes. Often these children are wrongly diagnosed as externalisation disorder (conduct, oppositional, ADHD) and more "penalisation" meassures are used "against" them which might push them deeper in depression, feelings of guilt, self-blame and self aqusiation.

It is a very interesting topic. There is a big difference between irritability and anger, it seems to me, and yet it is hard to think that the former might not lead to the latter, and/or feed from it. It is also interesting to consider that we describe tiny babies as born irritable, but I doubt we ever call them angry.

I think maybe that our society is frightened of anger and represses it rather than contains it, leaving people with guilt and frustration about what might be very justifiable negative feelings. There is a lot for people to be angry about in this world, afer all.

Watching a toddler have a tantrum can be very instructive, or rather seeing how a parent manages the tantrum. I saw a mother handle her young child's tantrum the other day in a shop and was deeply impressed by how she acknowledged it (accepted the feelings) but didn't give into them, nor criticise them). Her approach, which was gentle but firm and unembarrassed, gave me, an adult onlooker, a great sense of relief and security. I expect the child felt it too.

His feelings were validated in some way but contained, maybe too many of our children do not experience that. Some adolescent anger and irritabilty may need to be understood in this context.

HI Isabel and other respondents

I am also intrigued by this question as a counselling psychologist who does parent consultation on behavioural and emotional issues in childhood as well as working with adults suffering from anxiety and depression.

Isobel, you mentioned that there is a big difference between irritability and anger. Do you have any research which has looked at and clearly defined these constructs? please can you send me? Is there a link between irritability and anxiety?

I would also like to add another construct to this discussion - frustration. I think this is an often overlooked variable which was started to be developed by Dollard and Millar (pre-WW2) in the Aggression-Frustration Hypothesis but has been neglected in recent years. Is anyone aware of recent research working from this hypothesis? I am interested in exploring its relevance in understanding depression - if depression can be construed as internalised rage/aggression how is that linked to externalised aggression/irritability?

I think much light can be shed on the theoretical understanding of depression and aggression (as well as irritability and agitation) if we better understand the role of frustration (as an existential emotion). Maybe a distinction needs to be made between anger and frustration. Is anger a non-neutral emotion but frustration is a neutral one? ... these are some of my preliminary thoughts - does anyone have any feedback or found any literature around these ideas?

I also am interested in Attachment theory and the role an attachment figure plays in the soothing of a child who is agitated. If the soothing is effective and internalised (as an Internal Working model IWM) then will the irritability subside? be non-existent? what are your thoughts?

Attachment hunger (unmet attachment needs) are also a place of existential frustration that need to be grieved for the person to come to psychological rest.(free of irritability and agitation). Does anyone know of good literature to back up this hypothesis?

Mark, I would love to read the New Zealand research you mentioned - can you send me a copy, please?

Hi Ruth,

Very interesting post....which further complicates the scene, really! Isn't vocabulary important? We now have irritability, anger, frustration, agitation and anxiety in the mix, all interrelated and also tied up with not only parenting ad other environmental influences, but also with existential pain, which is suggestive of the human yearning to lead a meaningful, if ultimately pointless, existence.

I think all these factors may help explain how different students of the different 'psychologies' sometimes do not really communicate fully with one another: the deeper implications of vocabulary and constructs are not shared. I personally think the DSM's use of the word irritable seems further and further away from describing 'reality' as it is experienced by many people (not just the 'angry adolescents Nick is coming across), and that this is reflected in the debate (very current in the UK) on its usefulness.

However, it is also vital, it seems to me, to find shared meanings, and research them.

Sorry, no, I have no research on any of these areas, though I am interested.

Isabel

September 18, 2013

Hello Fellow ResearchGate(rs),

RE: Irritability, Anger, Frustration. Anxiety

This on-going discussion exemplifies the co-morbidity that exists among these various characteristics. Not being one who performs research (but one who devours tons of it), I come from more of a lived experience perspective developed over decades of embarking upon my own quest for understanding.

There is a huge difference, for instance, between anger and frustration with overtones of opposition and defiance. Allow me to explain.

Many youth express (self) frustration over attempting to complete a task (e.g. re: executive dysfunction) that gets misinterpreted as anger especially relative to a meltdown as seen in ADHD. Bear in mind that frustration ranges from “mild to wild” and generates no small amount of anxiety, especially when either anticipating or encountering a new task. Having a history of “incompleteness” sharpens one’s inability to “get off the mark.” It’s not that such individuals don’t know what’s being requested of them, rather that they cannot find the jumping off point. As a result they become overwhelmed. This is not to suggest that self-anger doesn’t develop with the accompanying degradation in one’s quality of self-esteem as well as with one’s senses of confidence and competency.

Further, when challenged to “perform” (e.g. academically or socially) these sorts of individuals can readily become defensive or as some would suggest, oppositional and defiant. Well, if you had such challenges as ADHD, BiPolar, Tourette and any comorbid cocktail, you’d for sure be a bit oppositional and defiant as well. Seen in that light it’s an appropriate survival attitude.

Clearly, at least in my mind, mood/emotional issues (e.g. anger) are quite different from cognitive ones (e.g. frustration) although many have both (e.g. ADHD & BiPolar). I like to say that ADHD is, at its core, a cognitive issue with emotional overtones while BiPolar is, at its core, an emotional issue with cognitive overtones. As that old song goes “You can’t have one without the other” (a la Love and Marriage by Frank Sinatra).

And then, there’s the aspect of trauma that also deserves recognition. Think about having a neuro-bio condition that is, in effect, traumatizing/stressing one from the inside out. Here’s the scenario:

Stress traumatizes the individual. Being traumatized is a stressful experience.

Is it no wonder these kids are anxious?”

If one truly wants to characterize these aspects with clients, may I humbly suggest that you first inquire of the client as to how they perceive what they are feeling and doing and allow, nee encourage, them to describe it for you. Doing such has two very beneficial outcomes.

First, it alleviates the counselor form having to do something TO someone else (i.e. define their existence for them) and Second, it assists the client by helping them to “cognitize” their own experience in ways that make sense to them. In essence, that paradigm elicits meta-cognitive insight, what Westerners prefer to call mindfulness. To me it’s Tao-istic/Zen.

While I appreciate attempts to quantify such “personality and or pathological traits” via research studies, in the final analysis, understanding one’s condition is paramount. The therapist’s job as I see it is to assist others in developing their own insight into what ails them.

Do I think it’s important to be able to distinguish between such things as frustration, irritability and anger? I do. I do because it’s one way I try to get a handle on what “it” is, namely do we have a diagnostic name for what we are observing. It’s like needing to know the difference between a dislocation and a broken bone. The interventions are decidedly different. Rather than come to a conclusion by oneself though, I suggest working with clients by including them in the process of discovery.

Garry,

I love this posting, for its scrupulous attention to detail and its closely analysed argument.

All I want now is a fuller description of the last part: "The interventions are decidedly different", and to ask whether you have good reading to recommend on research linking frustration and anger to adolescent depression, or is that a link that isn't made?

Isabel,

Thanks for the kind words.

Clearly, clinically speaking, when people are stressed, which frustration generates (along with the anxiety), depression can easily result, as different from the organic version. I'd take a look at the HPA axis re: the connection between cortisol levels (the stressor hormone) and serotonin receptors as one thing to consider.

Thanks again.

Yes, thanks all - I won't respond in detail to all that has been written now, except to say that we are trying to do exactly what Garry has suggested (or at least one aspect of it), i.e. we have been talking to a large group (70-80) of adolescents themselves about their experience of depression (they have all been referred to clinical services), i.e. what they 'are feeling and doing' and asking them to describe it to us as fully as they can and in their own words, at their own pace. It is a longitudinal study as well, so we are going back and interviewing these same adolescents six months later (after they have received some kind of therapeutic intervention - so we also talk to them about their experience of that) and again one year after that - to see how they make sense of their experience over time.... I'll keep you posted - but have found this discussion extremely helpful - so thank you!

In earlier decades it was thought that children could not be depressed. I haven't traced that through DSM just remember through my training. This is somewhat gratuitous but I am reminded of the teacher who wrote on every third grader's report card to the parent "your child is silly." This was a male teacher who didn't know the definition of 3rd grade. With that in mind, it is important to define irritability; as one person wrote earlier we have measures of new borns such as EASI. When it comes to older children it is important to separate out irritability from over anger and we do this with observation, performance assessment and interviews (of parents , teachers etc). This requires an instrument such as an observation protocol or an interview guide; usually they will have the behavior described in terms of "severity , chronicity, and frequency." Even with carefully defined protocols it is often difficult to obtain inter-rater reliability. In a study with Boston Children's hospital we had teachers and nurse practitioners looking for behaviors and it was difficult to get reliability. Again, not to be facetious or fatuous I just love Joel Gray's rendition of "If you could see her through my eyes." I don't mean to write in a pejorative sense here but just to say "you know it when you see it" but can we get various observers agree? I know when a parent comes to me and says the teacher said "chis child has attention deficit ; or is hyperactive" I always ask the parent does the doctor see it too? or, just the teacher? I am apologizing for gratuitous statements and for anything that might be seen as "pejorative" in my communications in an effort to fully understand young students and their behaviors in a useful manner than can lead to intervention or the decision not to intervene as these are always judgment calls.

Jean, I like your posting,it goes to the heart of the matter in a practical everyday way. Research is one thing, daily working life with children and young people is another. Bringing them together and sharing language and observation skills is a challenge.

Irritability, aggressivity and compulsions are frequent features of depression among children and adults, as well.

They can lead to criminality as group murders (see the face of the murder of the kids at school and listen to the story of the one at Navy's Ministery).

Compulsion can be sexual, explaining crimes.

It is a pity that the cause is overlooked because an adequate treatment could avoid many problems for the patient (and their victims!)

I'm responding to Isabel here. I dropped out of the discussion because it seemed to be taking a different turn from what I would expect . I am concerned that taking one "symptom" (if it is that) and focussing in without looking at developmental levels in children is narrowing the discussion. What is a child's development task if he/she is to develop frustration tolerance? Every mother and grandmother (and most elementary school teachers) no that irritability will come along with the territory and should not be singled out as a "symptom." I am laughing a little bit because a researcher was on the TV this week with a study and she quoted that mom "gave the child opportunity for a nap." It implies a lot about raising children I guess and my particuar bias would show to much.... need for structure etc. But at any rate , just concentrating on irritabiity could make trivia become triumphant. If this is offensive to anyone I will withdraw the statements. If I were studying emotions, mood lability etc then I might find a place for "irritability"; otherwise , we could say that measles is just a skin rash? We need to have the "Janus" two-faces looking in more than one direction.

Asking people "what works" for them and then imitating what they do if we also want to be successful is something that first took hold in the business world (cf. Jay P Greene, University of Arkansas) . Greene has a little "snark" attached but if you wade through his article he explains what is called “selection on the dependent variable.”

A research design needs to include operational definitions (with measures that can be used with proven reliability including inter-rater agreement). Some terms become popular in the marketing literature (a typical example today is "grit") but then it needs a concept behind it as well as measures that are reliable and valid or it doesn't hold up over time. In the Boston Children's Hospital study in urban, high poverty schools it took two years to get the inter-rater reliability between and among teachers, nurse practitioners etc on our rating scales before the instruments could be reliably used. Also, see the book "Black Swans" by U Mass professor as he would encourage research design would help to explain variation in the dependent variable; and not all fitting neatly into a "bell curve" because you are working with distinct populations with known diversity.

Jean, I think you are alerting us to the need for a child's 'attachment' status to be considered in our reflections on this topic. Ruth did so earlier and there has been mention of how irritability and anger might relate in this context.

I couldn't agree with you more that constructs such as irritability need to be seen as part of a big picture. I was at a lecture last night by Iain McGilchrist who has written about the importance and value of 'right-brain-thinking' in a world that is increasingly capable of, and interested in, atomising, of analysing 'details'. This is very valuable but is too often at the expense of intuiting and linking and gaining understandings of the 'whole'.

http://www.psychoanalytic-council.org/civicrm/event/info?id=2

After all this post I am still not sure what is Irritability and how to diagnose it.

This is important pharmacological question since for example only two meds are indicated to treat irritability in autism, but not for other feature of autism like agitation or hyperactivity or "severe behavioral disturbances" which may look similar. All this terms are from FDA indication table for antipsychotics.

I appreciate if someone could give me some ref in which irritability in depression is described, or even better some measure for it. What if we have depressed kid which had fight because irritability and other one who had conduct disorder. Are school will punish both of them (which will be catastrophic for the first one). maybe for other too.

How to distinguish them. I am clinician and probably will be able to do that, but on academic level what is difference between "different" kinds of irritability.

personally, I would go back through my earlier documents/texts and look at frustration tolerance.... it is significant in developmental psychology.... I favor the British school such as Guntrip over the way the U.S. makes it "formulaic" with the listing of criteria within a syndrome etc.... if you wanted any more on the British school (cf. Guntrip and others) I would be glad to share that ; I know there are many who oppose that view....

This is in reply to Tomislav: this only touches the surface of your question.

Dunnedin study (Caspi 2000); those children found to be emotionally labile, restless, and impulsive are, compared with so-called inhibited children, about three times more likely to become adults with antisocial personality. I haven't fully examined this study but I will look further into it because you have a very important question here.... thanks for getting me inspired...

Specific to the question Tomislav asks: January 01, 2012

Adolescent Irritability: Phenotypic Associations and Genetic Links With Depressed Mood

Argyris Stringaris, MD et al

Am J Psychiatry 2012;169:47-54. doi:10.1176/appi.ajp.2011.10101549

------------------------

Again, this only touches the surface of your question; I was looking for temperamental characteristics of children (early development age 3 etc...

this question is fascinating to me and I think you might want to start a new thread/topic to have a discussion on all of the issues it raises

Dr. Stringaris has done excellent work on irritability in young people. I am adding this reference to the thread as it is also relevant I think.

http://www.ncbi.nlm.nih.gov/pubmed/23880493

J Am Acad Child Adolesc Psychiatry. 2013 Aug;52(8):831-40. doi: 10.1016/j.jaac.2013.05.017. Epub 2013 Jul 3.

Irritable mood as a symptom of depression in youth: prevalence, developmental, and clinical correlates in the great smoky mountains study.

Stringaris A1, Maughan B, Copeland WS, Costello EJ, Angold A.

This one as well; good overview on how irritability is defined/described in many disorders in the DSM.

Irritable mood and the Diagnostic and Statistical Manual of Mental Disorders

Daniel J Safer

Child and Adolescent Psychiatry and Mental Health 2009, 3:35 doi:10.1186/1753-2000-3-35

http://www.capmh.com/content/3/1/35

in a child as young as 4 I saw this but I call it "frustration tolerance"… her parents had recently split and she was thinking about happy memories in Maine and looking at pictures of her family;  there were many , many sighs.   She was able to verbalize it as "I love Maine" (that is a good indication that she was attempting to integrate the many emotions involved)   It was one of the first times I had viewed it in a 4 year old child and the sighs were key ; she was struggling with a loss.  She had other "frustration" tolerance episodes during a 3 or 4 hour time span but there was her grandmother and myself to help her deal with it.  Look at Vygotsky's work on how to support and scaffold a child ….  There are developmental steps that occur.  (p.s. her grandma and grandpa are taking her from MA to Maine on one day to visit before winter and that is another step in her growth to be with loving and caring persons)

Yes, Miyuru…  the anecdotal observations of very young children tell us a lot and we learn about human behaviors.  I have done a lot of observation of children in "play" therapy and it is fascinating to see how they work out different themes.   They will act out a "story" whether they know you are watching or not.  They often need to practice the "attachment" behaviors and if they can verbalize it even with a doll or a stuffed toy that is helpful.  I did notice all the sighs in the one 4 year old.   If a teacher looked at the child she would see the glasses and hear the speech sounds (not always clear) and might dismiss the child  as "not learning"  but when you actually see the child's play and interpret her stories there is so much there -- and it reaffirms the child's individual capacity for growth.  This has been a special interest of mine working with preschoolers and early childhood.  if you want to write an email I am [email protected]  (Massachusetts/USA/retired adjunct faculty -- we trained school psychologists) and we had help from Children's Hospital in Boston with the nurse practitioners (in less affluent areas of  MA where we have multi-ethnic populations)

Dear Jean and others

I like that you term it Frustration

I have been studying the work of developmental psychologist Gordon Neufeld who has a model of frustration leading to aggression in children - I understand irritability to be an outcome or behavioural emotional manifestation of frustration (amongst other factors due to unresolved grief or feelings of futility - powerlessness - links with the learned helplessness model - especially when a child sighs a lot)

Neufeld's model of frustration - aggression is founded on the original work by Dollard and Miller

The model states that a child (or an adult) experiences frustration when they encounter futility - things they cannot change or have not control over. This can lead to two outcomes - adaptation or aggression. If the child is not defended against vulnerability, then they adapt through a process of grieving (tears are a sign that the emotional movement has changed from the sympathetic nervous system arousal - aggitation and irritability is a sign of this being present - to coming to psychological rest and acceptance - that is a sign that the child/adult has shifted to parasympathetic nervous system activation. however, the other outcome outbursts of aggression, is inevitable if the child is defended against their feelings of vulnerability. This aggression can be either inner directed (internalising problems like negative self-talk, self-blame, self attack suicidal ideation, the roots of depression) or it can be outward directed (externalising problems  - verbal, physical aggression -  other-blame - which can be associated with learned helplessness).

Neufeld has not written this up in an academic journal but has presented it in DVD form - see www.neufeldinstitute.com - especially his courses on Making sense of Aggression http://neufeldinstitute.org/course/making-sense-of-aggression/

if you would like to do more correspondence my email is [email protected]

Hello Everyone,

Well, I see where this topic continues to generate interest.  I've posted extensively in the past on this issue which began with the discussion of irritability as a sign of adolescent depression.  (See initial posting by Nick Midgley).  So, it went from irritability, to anger, to rage and included temperament, anxiety and frustration.  To me, such a wide-ranging discussion really speaks to the very breadth and depth of child and adolescent mood states.  Allow me to comment a bit more.

Perhaps nothing is more daunting in child & adolescent mental health (C&A MH) than that of trying to decipher "exactly what it is" when confronted with various mood states, especially in young children.  Is it neurological in origin? Cultural? Parenting?  Or, of course the often overlooked, Trauma?  All, no doubt, play a role.  As I pondered this conundrum I realized the wide swath that C&A mood states inhabit.  To add to that is the fact that, children especially, "morph" very quickly, particularly in regard to mood.  (Note, I prefer the use of mood rather than temper or anger.)   So now we are confronted with a myriad of conditions of which mood is a major component concern. The task is how to determine a coherent diagnosis.  Is it Early Onset Bipolar, ADHD, RAD, OCD, etc., etc.????   You get the picture.

I attempted to address this in a program I developed entitled "Out Of Control Kids: Intervening With Temper Tantrums, Meltdowns & Rage Attacks,"   It offered a paradigm that distinguished those manifestations from each other and posited concepts necessary for intervening with such "severe emotional episodes." 

Determining the "Core" of a condition as either cognitive (e.g. ADHD - cerebral cortex) or emotional (e.g. BiPolar - limbic/amygdala) ) can guide one's approach.  if it's cognitive in nature, then one needs to be careful about overloading an already overloaded cognitive system.  Too much verbal input that requires more cognitive processing isn't helpful as is trying to out-logic someone with BiPolar when it's not really about content but intensity.  Both will generate legions of frustration.  

Such frustration, though, manifests quite differently.  With ADHD we get meltdowns, decidedly different from BiPolar rages.  Of course, then there's the interference of all the potential co-morbid aspects. 

I appreciate Neufeld's work and came upon him relative to bullying.  Ross Greene's treatise on frustration in The Explosive Child, was helpful in conceptualizing frustration and its quota for tolerance.  I do believe, though, that the approach (i.e. different baskets and meltdown avoidance) was simplistic. 

I hope this discussion continues as it is extremely important to developing understanding and acceptance in working with children, adolescents and their families faced with the vagaries and challenges of  mood dysregulation.