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International Journal of Methods in Psychiatric Research logoLink to International Journal of Methods in Psychiatric Research
. 2023 Sep 20;32(Suppl 1):e1991. doi: 10.1002/mpr.1991

Prevalence, stability, and predictive utility of the Multidimensional Assessment of Preschoolers Scales clinically optimized irritability score: Pragmatic early assessment of mental disorder risk

Jillian Lee Wiggins 1,2,✉, Ana Ureña Rosario 1, Leigha A MacNeill 3,4, Sheila Krogh‐Jespersen 4, Margaret Briggs‐Gowan 5, Justin D Smith 6, Lauren S Wakschlag 3,4
PMCID: PMC10654826  PMID: 37728118

Abstract

Objectives

Characterizing the scope and import of early childhood irritability is essential for real‐world actualization of this reliable indicator of transdiagnostic mental health risk. Thus, we utilize pragmatic assessment to establish prevalence, stability, and predictive utility of clinically significant early childhood irritability.

Methods

Data included two independent, diverse community samples of preschool age children (N = 1857; N = 1490), with a subset enriched for risk (N = 425) assessed longitudinally from early childhood through preadolescence (∼4–9 years old). A validated, brief (2‐item) scale pragmatically assessed clinically significant irritability. In the longitudinal subsample, clinical interviews assessed internalizing/externalizing disorders.

Results

One in five preschool‐age children had clinically significant irritability, which was independently replicated. Irritability was highly stable through preadolescence. Children with versus without clinically significant early childhood irritability had greater odds of early onset, persistent internalizing/externalizing disorders. The pragmatic assessment effectively screened out low‐risk children and identified 2/3 of children with early‐onset, persistent psychopathology.

Conclusions

Clinically significant early childhood irritability prevalence is akin to the pediatric obesity epidemic and may warrant similar universal screening/intervention. Also, irritability's stability demonstrates the common guidance “they'll grow out of it” to be false. Finally, pragmatic irritability assessment has transdiagnostic predictive power and addresses a need for feasible measures to flag risk.

Keywords: childhood, irritability, prevalence, psychopathology, stability

Abbreviations

ADHD

Attention Deficit Hyperactivity Disorder

AOR

Adjusted odds ratio

CD

Conduct Disorder

CI

Confidence Intervals

DSM

Diagnostic and Statistical Manual of Mental Disorders

Dys

Dysthymia

GAD

Generalized Anxiety Disorder

ICC

Intraclass correlation

K‐SADS‐PL

Kiddie Schedule for Affective Disorders and Schizophrenia‐Present & Lifetime Version

M

Mean

MAP‐DB

Multidimensional Assessment Profile of Disruptive Behaviors

MAPS

Multidimensional Assessment of Preschoolers Scales

MDD

Major Depressive Disorder

N

Number of observations/participants

ODD

Oppositional Defiant Disorder

PAPA

Preschool Age Psychiatric Assessment

RDoC

Research Domain Criteria

SAD

Social Anxiety Disorder

1. INTRODUCTION

Despite the prominence of behavioral health concerns for young children in pediatric practice, there is surprisingly little clinical guidance on identification for providers (Boat & Kelleher, 2020). Identifying vulnerability to psychopathology as early as possible (i.e., early childhood) within the neurodevelopmental sequence is key to prevention, a crucial insight from the Research Domain Criteria (RDoC) framework (Mittal & Wakschlag, 2017). Elevated irritability is the most robust early marker of transdiagnostic vulnerability to common and modifiable psychopathologies (i.e., internalizing and externalizing syndromes) (Valencia et al., 2021; Wakschlag et al., 2018). In the provider's office, elevated irritability may present as complaints about frequent and/or severe tantrums and irritable mood (Brotman et al., 2017; Wakschlag et al., 2015; Wiggins et al., 2018), yet providers face a high level of decisional uncertainty as to whether such behavior is normative and/or transient versus an indicator of emergent psychiatric problems. Elevated irritability is a core feature of disruptive mood dysregulation (DMDD) and oppositional defiant (ODD) disorders but also a common feature and frequent target of pharmacologic treatment in school age/adolescence in other syndromes, including mood (DSM‐5, 2013), anxiety (DSM‐5, 2013), attention deficit (Karalunas et al., 2019), and autism spectrum (Robb, 2010) disorders. However, providers currently lack pragmatic tools for differentiating early problematic behavior (Glasgow, 2013; Morris et al., 2020).

To prospectively capture irritability in line with RDoC principles, we developed the Multidimensional Assessment Profile Scales Temper Loss (MAPS‐TL) scale, a 22‐item parent‐report irritability spectrum assessment based on novel developmental specification theory, positing that clinically concerning versus normative irritability is differentiable within developmental context (Wakschlag et al., 2012). The MAPS‐TL was designed was to provide dimensional indicators of early neurodevelopmental vulnerability to psychopathology and captures the quality, objective frequency, severity, and contexts of irritable behavior and mood in a developmentally sensitive manner. Its normal:abnormal spectrum has been validated in three large, independent community samples in preschool age (Krogh‐Jespersen et al., 2021; Wakschlag et al., 2018), and emerging work has validated versions for youth (Alam et al., 2023; Hirsch et al., 2023; Kirk et al., 2023) and infant‐toddlers (Krogh‐Jespersen et al., 2021; Wiggins, Ureña Rosario, et al., 2023). This dimensional spectrum approach revealed that atypical versus normative irritability is distinguishable during this period by irritable behaviors' frequency, dysregulation, and occurrence in developmentally unexpectable contexts (Wakschlag et al., 2012). Such early atypical irritability is marked by altered neural patterns (Wakschlag et al., 2018; Dougherty et al., 2018; Grabell et al., 2018; Deveney et al., 2019; Damme et al., 2022) and predicts subsequent impairment and psychopathology (Wakschlag et al., 2020; Wiggins et al., 2018, 2021).

A key barrier to clinical translation of the RDoC transdiagnostic approach has been the absence of pragmatic approaches feasible for real world use (Glasgow, 2013; Morris et al., 2020). Pragmatic measurement is practical and actionable in the real world, broadly applicable, publicly available, and brief (Glasgow, 2013). Although single‐ or few‐item scales have been traditionally rejected as potentially unreliable, renewed interest in the advantages of pragmatic measurement for screening purposes (i.e., not complex characterization of multidimensional psychological constructs) (Allen et al., 2022) has made inroads in adult clinical care, although pragmatic measurement has not yet had appreciable impact in children's mental health. (Blackwell et al., 2020; Wakschlag et al., 2023). To advance pragmatic approaches to clinically salient early irritability assessments, we previously utilized robust psychometric methods to empirically derive a brief, 2‐item version of the MAPS‐TL for preschool age children (∼4 years of age) (Wiggins et al., 2018). These two items (“easily frustrated”, “destructive tantrums”) were derived from the dimensional severity spectrum highlighting the utility of objective frequency scaling (vs. the subjective “often” criteria utilized in Diagnostic and Statistical Manual of Mental Disorder [DSM]) for normal:abnormal differentiation. The two items were formulated as a Clinically Optimized Irritability Score that sensitively and specifically identified children who met criteria for concurrent irritability‐related DSM disorders (DMDD, ODD, or other depressive disorders) (Wiggins et al., 2018). That is, “easily frustrated” is common, occurring regularly in about two‐thirds of preschoolers. Thus, a very high frequency threshold for frustration is necessary. By contrast, “destructive tantrums” are a pathognomonic indicator, which nearly three‐quarters of preschoolers do not exhibit regularly. Thus, if frustration is less frequent, the additional presence (even if rarely) of destructive tantrums is required. Such clinically significant irritability is useful for identifying children at risk for internalizing/externalizing disorders in early childhood, as well as sustained impairment through school age (Wiggins et al., 2018). This brief survey method is, to our knowledge, the first “efficient” developmentally‐grounded irritability assessment tool designed to differentiate normative from clinically significant irritability in young children. We have since expanded this approach for pragmatic screeners for the transition to toddlerhood (Wiggins, Ureña Rosario, et al., 2023), early school age (Hirsch et al., 2023), preadolescence (Alam et al., 2023), and adolescence (Kirk et al., 2023) in this issue.

This prior work lays the foundation for brief, efficient irritability screening as a potential transdiagnostic marker of mental health risk for the most common and modifiable early‐onsetting internalizing/externalizing psychopathologies of childhood. Rather than prediction of specific syndromes, we take a transdiagnostic approach, predicting any internalizing and/or externalizing psychopathology, as many evidence‐based treatments in young children focus on parent training, which is preventive for both syndrome domains (Smith et al., 2020) due their shared risk architecture (Hyman, 2019). Moreover, a broad‐based approach is crucial to uptake in community settings (Walkup et al., 2017), such as pediatric primary care—the ideal venue for such a screening instrument to have the widest impact as virtually all children in the US have a pediatrician with whom they have routine contact (Wakschlag et al., 2019; Walkup et al., 2017).

Although our prior work was the first to empirically derive a cutoff for clinically significant early childhood irritability (Wiggins et al., 2018), a number of gaps remain that impede translation: (1) Prevalence: How common is clinically significant early childhood irritability? Is it an important public health problem? Particularly, what is its prevalence, and are patterns replicable and generalizable? (2) Stability: Is clinically significant early childhood irritability a stable phenomenon, that is, is it a marker for chronic irritability or will young children naturally “grow out” of it? This is not merely a theoretical question. For example, prevailing beliefs that early irritability is inherently unstable (Benarous et al., 2021) underlie the current exclusion of children under 6 years from DMDD disorder (Wiggins et al., 2021). (3) Predictive Utility: What is the likelihood that children with clinically significant early childhood irritability will exhibit the most severe form of psychopathology, that is, early onset and persistent, into preadolescence?

Taken together, this knowledge is the essential next step in moving toward real‐world actualization of irritability's potential as a broad‐based indicator of young children's mental health risk. To address these questions in a manner conducive to clinical use, in the current study, we utilized our pragmatic two‐item preschool irritability assessment to establish, then replicate, prevalence in two large, independent samples of preschool age children (Aim 1) and examine stability (Aim 2) and predictive utility (Aim 3) in a sub‐sample followed through preadolescence.

2. METHOD

2.1. Participants

Data were from the Multidimensional Assessment of Preschoolers Study, which comprises two independent, diverse community samples of children stratified by ages 3, 4, and 5 (N = 1857, N = 1490), recruited from multiple pediatric clinics in the Chicago area (Wakschlag et al., 2015). In addition to a baseline survey assessment with all participants in both community samples, we drew a subset of preschoolers from the primary community sample (N = 1857), enriched for clinical risk, as a laboratory‐based longitudinal subsample (N = 425) (Dirks et al., 2019), which was assessed twice in early childhood (M = 4.7 years of age, SD = 0.85; M = 5.4 years, SD = 0.91), in early school age (M = 7.1 years, SD = 1.1), and in preadolescence (M = 9.3 years, SD = 0.76). The secondary community sample (N = 1490) (Dirks et al., 2019) was drawn for the purposes of survey calibration/replication, but was not followed longitudinally. For Aim 1 (prevalence), we leveraged the two independent samples to establish, then replicate, prevalence rates. Demographic characteristics of these samples have been previously reported (Dirks et al., 2019) and are shown in Table 1. For Aim 2 (stability) and Aim 3 (predictive utility), we focused on the longitudinal subsample. Of the N = 425 families at baseline who participated in the longitudinal subsample, n = 387 had both irritability and DSM diagnosis information at early childhood, n = 315 at early school age (81%), and n = 296 at preadolescence (94%). All available data were used for each analysis. Additional information about this sample is available in the Introduction of this special issue.

TABLE 1.

Participant demographics.

Primary community sample Secondary community sample Longitudinal subsample
All participants Meets cutoff Not meet cutoff χ2 df p All participants Meets cutoff Not meet cutoff χ2 df p All participants Meets cutoff Not meet cutoff χ2 df p
n 1857 383 1474 1490 299 1191 425 127 298
Girls, % 51.4 44.13 53.26 10.15 1 0.001 49.0 43.48 50.38 4.55 1 0.033 51.1 48.0 52.3 0.66 1 0.42
Child race/ethnicity, % 9.18 3 0.027 17.30 3 0.001 3.64 3 0.31
Black/African American 39.67 40.99 39.35 33.42 31.10 34.01 49.9 53.5 48.3
Hispanic 24.34 18.80 25.78 30.34 23.41 32.07 29.9 28.3 31.5
White 22.78 26.37 21.84 25.57 30.10 24.43 18.6 18.1 18.8
Other 13.19 13.84 13.03 10.97 15.38 9.49 1.6 0.0 2.3
Poverty status (%) 44.7 49.61 43.01 4.88 1 0.027 42.9 48.1 41.6 3.97 1 0.046 49.2 53.4 47.6 2.55 1 0.11
t df p t df p t df p
Child age at T1 (years) 3.83 (0.77) 3.76 (0.77) 3.85 (0.77) 1.871 1846 0.061 3.94 (0.79) 3.94 (0.80) 3.94 (0.80) −0.021 1488 0.983 4.66 (0.85) 4.51 (0.80) 4.72 (0.86) 2.42 423 0.016
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Note: Values within parentheses are standard deviations. Poverty reflects income‐to‐needs ratio (Barajas et al., 2008).

2.2. Measures

2.2.1. Clinically significant early childhood irritability

A subset of two items (“easily frustrated”, “breaks or destroys things during a tantrum”) from the MAPS‐TL scale, formulated as the Clinically Optimized Irritability Score (Wiggins et al., 2018), was used to assess clinically significant early childhood irritability. Parents rated items on an objective frequency scale over the past month from 0 (Never in past month) to 5 (Multiple times per day). The cutoff (sum score of 3), which represented very frequent frustration and/or the presence, even if rare, of destructive tantrums, showed good sensitivity (70%–73%) and specificity (74%–83%) to detect clinically significant levels of irritability in preschoolers and predicted concurrent and persistent impairment (△χ 2₂ = 43.82, p < 0.001) (Wiggins et al., 2018). Additional information about the Clinically Optimized Irritability Score as well as the MAPS‐TL full scale from which it was derived is available in the Introduction of this special issue (Wiggins, Roy, et al., 2023).

2.2.2. DSM 5 internalizing/externalizing disorders over time

In early childhood, the Preschool Age Psychiatric Assessment (PAPA) and, in early school age and preadolescence, the Kiddie Schedule for Affective Disorders and Schizophrenia‐Present and Lifetime Version (K‐SADS‐PL) (Birmaher et al., 2009; Kaufman et al., 1997) were used to assess for the presence or absence of the following DSM 5 internalizing/externalizing disorders: Generalized Anxiety, Social Anxiety in early school‐age and preadolescence or Separation Anxiety in preschool age, Major Depressive/Dysthymic (MDD/Dys), ODD, Conduct (CD), and Attention‐Deficit Hyperactivity (ADHD) Disorders. Inter‐rater reliability was monitored on 20% of interviews, with κ = 0.83–1.00 across diagnoses for the PAPA and κ = 0.79–1.0 for the K‐SADS‐PL. Supplemental Table 1 shows rates of disorders.

2.3. Analytic plan

2.3.1. Aim 1: Prevalence

To characterize and replicate prevalence of clinically significant early childhood irritability, we calculated the frequency of children meeting versus not meeting the cutoff for clinical significance in both primary and secondary community samples. We used chi‐squared tests to evaluate differences in prevalence by sociodemographic characteristics (child sex, poverty status based on income‐to‐needs ratio (Barajas et al., 2008), race/ethnicity).

2.3.2. Aim 2: Stability

To characterize stability of irritability, we used intraclass correlations (ICC) with two‐way mixed effects requiring absolute agreement, given our interest in detecting irritability escalations/declines over time. To maximize sensitivity to irritability changes, the Clinically Optimized Irritability Score was used dimensionally here (vs. the cutoff‐based score for Aims 1 and 3). 95% confidence intervals (CI) were generated to compare ICC estimates across different age periods.

2.3.3. Aim 3: Predictive validity

To characterize the predictive validity, we investigated whether clinically significant early childhood irritability predicts early onset, persistent psychopathology. We implemented logistic regression to evaluate whether clinically significant early childhood irritability is associated with greater odds of meeting criteria for any internalizing/externalizing disorders with onset concurrently at early childhood, and meeting criteria again at early school age and/or preadolescence (i.e., early onset, persistent psychopathology). Models adjusted for sociodemographic characteristics (child's sex, age, race/ethnicity, early childhood poverty status). We used two metrics of predictive validity: (1) adjusted odds ratios (AORs), which reflects the relative likelihood of children with versus without clinically significant early childhood irritability to develop early onset, persistent psychopathology, adjusted for sociodemographics; and (2) sensitivity and specificity, which reflect true positive and true negative rates, respectively, for clinically significant early childhood irritability predicting early onset psychopathology. To explore whether patterns differ by internalizing or externalizing domains, we conducted separate post‐hoc analyses. Analyses were conducted in IBM SPSS software (IBM, 2020).

3. RESULTS

3.1. Aim 1: Prevalence

In total, 20.6% (CI = [18.8, 22.5]) of children (n = 383 of N = 1857) in the primary community sample had clinically significant irritability, a rate strikingly similar in the secondary community sample (20.1%, CI = [18.1, 22.2]; n = 299 of N = 1490). In both samples, prevalence of clinically significant early childhood irritability was higher in boys versus girls and in poor versus non‐poor but did not differ by age (Supplemental Table 2).

3.2. Aim 2: Stability

In the longitudinal sample, irritability was highly stable across the four time points (ICC = 0.79, CI: 0.74–0.83) (twice in preschool age, once in early school age and once in preadolescence). Stability within the preschool age (ICC = 0.70, CI: 0.63–0.75) did not differ significantly from the stability from preschool to early school age (ICC = 0.72, CI: 0.65–0.77) nor from early school age to preadolescence (ICC = 0.68, CI: 0.53–0.77).

3.3. Aim 3: Predictive validity

Children with versus without clinically significant early childhood irritability had >7 times greater odds of early onset, persistent internalizing/externalizing disorders, adjusted for sociodemographic factors (AOR = 7.14, CI: 3.55–14.37, p < 0.001). This model correctly classified 86% of children overall, and clinically significant early childhood irritability explained 20.3% of the variance (Nagelkerke's R 2). Clinically significant early childhood irritability had good specificity, that is, performed very well screening out children at low risk of psychopathology, as 77% of children who did not go on to have early onset, persistent psychopathology did not have clinically significant irritability in early childhood. Sensitivity was moderate, as 65% of children who went on to have early onset, persistent psychopathology also had clinically significant early childhood irritability (see Table 2).

TABLE 2.

Logistic regression model results and classification indices.

Predicting an early‐onset, persistent pattern of … Overall model fit improvement with clinically optimized irritability score* Parameter estimate information for clinically optimized irritability score Sensitivity Specificity
χ2, df = 1 p R 2 AOR Wald χ2, df = 1 p AOR 95% CI
lower upper
…Any disorder 33.04 <0.001 20.3% 7.14 30.41 <0.001 3.55 14.37 65.22% 77.36%
…Externalizing disorders 35.09 <0.001 19.3% 8.56 29.98 <0.001 3.97 18.46 73.68% 75.33%
…Internalizing disorders 9.50 0.002 10.2% 4.36 9.24 0.002 1.69 11.26 60.00% 72.26%
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Note: R 2=Nagelkerke's percent variance explained, AOR = adjusted odds ratio of meeting versus not meeting cutoff for clinically significant early childhood irritability, adjusted for sociodemographic characteristics. Internalizing disorders included Generalized Anxiety (GAD), Social Anxiety (SAD) in early school‐age and preadolescence or Separation Anxiety in preschool age, Major Depressive/Dysthymic (MDD/Dys). Externalizing disorders included Oppositional Defiant (ODD), Conduct (CD), and Attention‐Deficit Hyperactivity (ADHD). “Any” disorder included these internalizing and externalizing disorders. *compared to baseline model with sociodemographic variables (child's sex, age, race/ethnicity, early childhood poverty status).

3.3.1. Post‐hoc analyses

Analyses to determine patterns of internalizing and externalizing disorders separately indicated that children with versus without clinically significant early childhood irritability were at very high risk (AOR = 8.56, CI: 3.97–18.46, p < 0.001) of developing early onset, persistent externalizing disorders. Sensitivity (73%) and specificity (75%) in relation to early onset, persistent externalizing disorders were good, indicating overall low false positives and false negatives.

Although lower than externalizing, odds of developing early onset, persistent internalizing disorders in children with versus without clinically significant early childhood irritability were still substantial (AOR = 4.36, CI: 1.69–11.26, p = 0.002). However, while specificity was good, as 72% of children who did not go on to have early onset, persistent internalizing disorders did not have early clinically significant irritability, sensitivity was slightly lower, in the moderate range, as 60% of children who went on to have early onset, persistent internalizing disorders were marked by clinically significant early childhood irritability.

4. DISCUSSION

To our knowledge, this is the first demonstration of the scope and import of a pragmatically‐assessed transdiagnostic indicator for long‐term pediatric mental health prognostication. First, we found that approximately one‐fifth of preschool‐age children have clinically significant irritability, an incidence rate generally consistent across diverse sub‐groups and replicated in an independent sample. Our findings are analogous to the prevalence rate (20%) of the pediatric obesity epidemic in the United States (Ogden et al., 2020), for which the US Preventive Services Task Force recommends, via primary care, universal screening and intervention for the 20% with the disease (Screening for Obesity in Children, 2017). Thus, a similar screening and intervention strategy for clinically significant early childhood irritability may be warranted given its prevalence and import for lifecourse morbidity and mortality (Inse and l, 2009; Wakschlag et al., 2019). In addition, contrary to popular “beliefs” about early childhood as a time of great instability (Benarous et al., 2021), we found that patterns of clinically significant irritability in early childhood are quite stable, demonstrating the common guidance “they'll grow out of it” to be a fallacy (Luby, 2012).

Strikingly, our findings suggest that this clinically optimized two‐item irritability screener has considerable predictive power as a “common denominator” red flag for varied internalizing/externalizing disorders. Preschoolers with elevated scores were 4–8½ times more likely to exhibit the early onset, persistent pattern of psychopathology, the form which represents the greatest, most pernicious public health burden (Moffitt & Caspi, 2001; Pine & Fox, 2015). The strength of this predictive tool is made even more useful by its brevity and ability to be broadly deployed without specialized clinical expertise. It is remarkable to validly, reliably capture this considerably elevated risk based on a two‐item irritability questionnaire, particularly given that prediction from the same behavior, using clinical interviews at preschool and adolescence, has often been much lower or comparable (Finsaas et al., 2018; Gaffrey et al., 2018; Kim‐Cohen et al., 2009). This improved prediction likely stems from the empirically‐guided optimization process by which we distilled the questionnaire down to key behaviors and removed other, less predictive behaviors that could contribute to “noise” (Wiggins et al., 2018).

Our demonstration that this pragmatic, two‐item parent‐report questionnaire can identify broad psychopathology risk is promising and may address an acute need for optimized measures that can be easily deployed across a variety of settings (e.g., primary care, schools, online) to identify a subset of at‐risk children and intervene at the earliest phase of the clinical cascade. Additional pragmatic applications are underway, such as computer adaptive testing (Wakschlag et al., 2019), which may improve specificity for specific disorders. This is an important advance as RDoC principles (e.g., transdiagnostic symptoms, identification in early stages of the clinical sequence (Mittal & Wakschlag, 2017)) have yet to be considered within a pragmatic framework. Translation of these findings to routine care settings will require melding neurodevelopmental and implementation sciences to investigate the usability and acceptability of the screening procedure and the strategies needed for integration into real‐world health care delivery systems. (Wakschlag et al., 2019). An important aspect will be considering how to frame mental disorder risk screening for public health consumption, as views of stigma and notions about mental health in young children by specialists versus the public vary widely (Sho et al., 2011) and could impede broad uptake. This will require patient‐centered inquiry that takes values, priorities, and perspectives of caregivers and healthcare professionals into account (Bauer & Kirchner, 2020).

Of note, clinically significant early childhood irritability was shown to be an excellent means of screening out children at low risk of psychopathology. That is, young children without elevated irritability scores were highly unlikely to exhibit early onset, chronic psychopathology, suggesting that this brief transdiagnostic questionnaire could be an effective way to identify children at very low risk whose screening can be relatively infrequent (e.g., annually). Having a low rate of false negatives is especially important when interventions are most effective at earlier stages, as is the case with the heightened neuroplasticity of early childhood, and when such programs have few, if any, potential negative impacts for recipients.

With regards to sensitivity, we found these two irritability items identified two‐thirds of children who will have persistent mental disorders up to 6–7 years later. Sensitivity was particularly strong for externalizing disorders, as the two items catch 3 out of 4 children who will have early‐onset, persistent externalizing disorders. This sizable group of children “looped in” by our brief questionnaire may follow an irritability‐related pathway to chronic pediatric disorders; such individuals will almost certainly need intervention. The smaller subset of children not identified by our brief questionnaire who nevertheless evidenced early onset, persistent psychopathology may represent a non‐irritable pathway (e.g., non‐irritable depression). Explicating this will require future investigation.

These findings suggest that routine screening for early irritability, coupled with evidence‐based prevention, have the potential to alter risk trajectories in the early stages of the clinical sequence. Moreover, our findings point to the potential need for a tiered screening approach, in which brief, early irritability screening identifies those children at high risk for chronic mental health problems, and follow‐on multi‐domain screening more precisely characterizes probabilistic risk. For example, using a personalized risk calculator approach, we recently showed that the combination of early irritability and adverse childhood experiences best discriminates young children who will versus will not develop subsequent psychopathology. (Wakschlag et al., 2023). Future research leveraging computational psychiatry approaches is needed to specify the constellation of intrinsic developmental (e.g., compensatory language skills) and extrinsic social‐ecologic (e.g., family cohesion and conflict) factors for precise estimation of risk. (MacNeill et al., 2021).

Our study must be considered within its limitations. Future work validating these clinical tools in larger, population‐based, representative samples followed through adulthood will be necessary to confirm our findings, test hypotheses, improve sensitivity for internalizing disorders, and establish overall generalizability. As the clinical translation process is iterative, additional research informed by feedback from phased implementation will be necessary (Ramsey et al., 2019; Schindler et al., 2017).

Overall, this study advances the goal of early identification of neurodevelopmental vulnerability to broad‐spectrum, chronic, early‐onset psychopathology using a pragmatic tool derived within the RDoC framework. The predictive utility of the Clinically Optimized Irritability Score shown here speaks to the central importance of irritability in psychopathologic pathways and lays the groundwork for targeting neurodevelopmental vulnerability with brief, clinically feasible tools. The largest challenge moving forward is one of implementation, as developing new health information technologies, changing pediatric practice workflows, addressing provider and parent perceptions of mental health in early childhood (including stigmatization), and the availability of evidence‐based intervention options will all be required for the promise of this research to be realized. (Wakschlag et al., 2019, 2023).

AUTHOR CONTRIBUTIONS

Dr. Wiggins conceptualized and designed the study, analyzed and interpreted the data, wrote portions of the initial draft of the manuscript, and revised the manuscript critically for intellectual content. Ms. Ureña Rosario analyzed the data and wrote portions of the initial draft of the manuscript. Drs. MacNeill and Smith assisted in interpreting the data and revised the manuscript critically for intellectual content. Dr. Wakschlag obtained funding, conceptualized and designed the study, interpreted the data, and revised the manuscript critically for intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

CONFLICT OF INTEREST STATEMENT

All authors report no conflicts of interest.

Supporting information

Supplementary Information S1

Click here for additional data file. (18.3KB, docx)

ACKNOWLEDGMENTS

We gratefully acknowledge our research team, with special thanks to Dr. Sheila Krogh‐Jespersen, for their contributions to this dataset. Special acknowledgment to Dr. Erica Anderson (Northwestern University) for oversight of clinical measurements. This study was supported by NIH R01MH082830, 2U01MH082830 to Dr. Wakschlag and U01MH090301 to Dr. Briggs‐Gowan. The other authors received no additional funding that contributed to this work. The funder (NIH) had no role in the design or conduct of the study.

Wiggins, J. L. , Ureña Rosario, A. , MacNeill, L. A. , Krogh‐Jespersen, S. , Briggs‐Gowan, M. , Smith, J. D. , & Wakschlag, L. S. (2023). Prevalence, stability, and predictive utility of the Multidimensional Assessment of Preschoolers Scales clinically optimized irritability score: Pragmatic early assessment of mental disorder risk. International Journal of Methods in Psychiatric Research, 32(S1), e1991. 10.1002/mpr.1991

[Correction added on 19 October 2023, after first online publication: The term ‘Multidimensional Assessment of Preschoolers Study’ has been changed to ‘Multidimensional Assessment of Preschoolers Scales’ in the title and Abbreviations.]

With pragmatic assessment implementable for pediatricians, we document the high prevalence and stability of irritability and its predictive value for early onset, chronic mental disorders.

DATA AVAILABILITY STATEMENT

Deidentified data are available upon reasonable written request to Dr. Wakschlag for non‐commercial purposes.

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Supplementary Materials

Supplementary Information S1

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Data Availability Statement

Deidentified data are available upon reasonable written request to Dr. Wakschlag for non‐commercial purposes.

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