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International Journal of Methods in Psychiatric Research logoLink to International Journal of Methods in Psychiatric Research
. 2023 Sep 18;32(Suppl 1):e1989. doi: 10.1002/mpr.1989

Advancing earlier transdiagnostic identification of mental health risk: A pragmatic approach at the transition to toddlerhood

Jillian Lee Wiggins 1,2,✉, Ana Ureña Rosario 1,3, Yudong Zhang 4,5, Leigha MacNeill 4,5, Qiongru Yu 2, Elizabeth Norton 4,5,6, Justin D Smith 7, Lauren S Wakschlag 4,5
PMCID: PMC10654830  PMID: 37723907

Abstract

Objectives

In light of the youth mental health crisis, as 1 in 5 children have a mental disorder diagnosis by age 3, identification of transdiagnostic behavioral vulnerability prior to impairing psychopathology must occur at an earlier phase of the clinical sequence. Here, we lay the groundwork for a pragmatic irritability measure to identify at‐risk infant‐toddlers.

Methods

Data comprised N = 350 diverse infant‐toddlers and their mothers assessed at ∼14 months old for irritability (Multidimensional Assessment Profiles‐ Temper Loss‐Infant/Toddler (MAPS‐TL‐IT) and impairment (Early Childhood Irritability‐Related Impairment Interview, E‐CRI; and Family Life Impairment Scale (FLIS). Bimonthly follow‐up surveys assessed impairment (FLIS) over the following year.

Results

Stepwise logistic regression indicated that 5 MAPS‐TL‐IT items were most informative for differentiating concurrent impairment on the FLIS: “frustrated about small things”; “hit, bite, or kick during tantrums”; “trouble cheering up when grumpy”; “grumpy during fun activities” and “tantrums in public”. With this summed score, Receiver Operating Characteristics analysis differentiating concurrent impairment on the E‐CRI indicated good classification accuracy for (Area under the curve = 0.755, p < 0.05), with a cutoff of 5 maximizing sensitivity (71.4%) and specificity (70.6%). Elevated irritability on this MAPS‐TL‐IT clinically optimized screener increased likelihood of persistently elevated FLIS impairment trajectories over the following year more than fourfold (OR = 4.37; Confidence intervals = 2.40–7.97, p < 0.001).

Conclusions

Our findings represent the first step toward a pragmatic tool for screening for transdiagnostic mental health risk in toddlers, optimized for feasibility in clinical care. This has potential to strengthen resilience pathways via earlier identification of mental health risk and corollary prevention in toddlers.

Keywords: infant, irritability, pediatric, risk, screening, toddler, transdiagnostic

1. INTRODUCTION

The U.S. is currently in a youth mental health crisis, worsened by the pandemic and amplified for youth from historically marginalized communities (Stephenson, 2021; AAP‐AACAP‐CHA). A key opportunity for addressing this crisis is to improve detection and prevention of mental health risk prior to frank disorder onset via pragmatic methods that would allow population‐level screening for transdiagnostic behavioral vulnerability in early childhood during routine pediatric care (Wakschlag et al., 2019). Transdiagnostic approaches involve cross‐cutting indicators of multiple syndromes and are critical to real world implementation where practical concerns constrain a syndrome‐specific approach (Walkup et al., 2017). Identifying vulnerability to common pediatric mental health problems, that is, internalizing and externalizing syndromes, needs to occur very early, as 1 in 5 children have a mental disorder diagnosis by the age of 3 (Dougherty et al., 2015; Stephenson, 2021).

Elevated irritability is the most robust transdiagnostic indicator of early childhood behavioral vulnerability to psychopathology (Wakschlag et al., 2018; Klein et al., 2021; Wiggins et al., 2023), and can be conceptualized as a low threshold for anger in response to frustration, relative to peers (Beauchaine & Tackett, 2020; Brotman et al., 2017; Evans et al., 2017). Our work in infants/toddlers, preschool age, early school age and pre‐adolescent children supports a single dimension characterizes the normal:abnormal spectrum of irritability (Krogh‐Jespersen et al., 2021; Wakschlag et al., 2012; Hirsch et al., 2023; Alam et al., 2023). While there is some evidence for tonic (mood) versus phasic (outburst) components in older children (i.e., early school age through adolescence; Zhang et al., in press; Silver et al., 2023; Silver et al., 2021), any such distinctions are attenuated in younger children (preschool age; Silver et al., 2022). Indeed, our work on infant/toddlers shows irritability behaviors to lie on a single dimension (Krogh‐Jespersen et al., 2021). To date, the vast majority of early childhood irritability research has focused on preschool age (3–6‐year‐olds) (Carlson et al., 2016; Dougherty et al., 2015; Ezpeleta et al., 2020; Grabell et al., 2018; Wakschlag et al., 2015). Drawing on the Research Domain Criteria neurodevelopmental, dimensional framework (Cuthbert, 2020), we developed the Multidimensional Assessment Profiles Temper Loss (MAPS‐TL) scale to differentiate typical from atypical features of irritability within the developmental context of early childhood along the normal‐abnormal spectrum. We validated this ssurvey tool in over 3000 preschoolers across two independent samples (Wakschlag et al., 2015, 2018), including for clinical and mechanistic prediction (Wiggins et al., 2021, 2023; Damme et al., 2022). With the MAPS‐TL tool, we documented that elevated irritability, expressed via tantrums and irritable mood, is normative misbehavior in preschool age. However, atypical patterns of irritability can be distinguished from normative misbehavior in preschoolers based on their frequency, dysregulation, and occurrence in developmentally unexpectable contexts (Wakschlag et al., 2012; Wiggins et al., 2018). Atypical irritability in preschool age predicts greater psychopathology, functional impairment, and service use by school age (9 years) (Dougherty et al., 2015). Moreover, atypical irritability has been demonstrated to be marked by neural alterations in preschool age (Grabell et al., 2018; Kessel et al., 2016) and older (Brotman et al., 2017; Damme et al., 2022; Dougherty et al., 2018; Nielsen et al., 2021). Preschool age atypical irritability is associated with concurrent impairment as well as downstream detrimental consequences across the lifespan, including greater incidence of depression, anxiety, and suicidality as well as poorer educational and socioeconomic outcomes in adulthood (Liu et al., 2018; Sorcher et al., 2022; Wiggins et al., 2018).

Drawing on this well‐validated dimensional tool, we have begun to advance a pragmatic approach, emphasizing tools optimized for real‐world use that are brief, efficient, and maximally sensitive for clinical prediction (Morris et al., 2020; Wakschlag et al., 2018). To achieve this at preschool age, we derived empirically based thresholds to sensitively and specifically identify clinically significant irritability based on impairment (Wiggins et al., 2018). From the 22 irritability items of the MAPS‐TL, we derived a clinically optimized screener comprised of two behaviors (“easily frustrated”, “destructive tantrums”) that explained the bulk of the variance in preschoolers. An empirically‐derived frequency cutoff for these two behaviors identified concurrent preschool age and future mental disorder diagnostic status with good specificity and sensitivity (Wiggins et al., 2018). This work showed that clinically significant irritability can be identified pragmatically in preschool age with predictive utility (Wiggins, Ureña Rosario, Zhang et al., 2023), which we have since expanded to early school age (Hirsch et al., 2023), preadolescence (Alam et al., 2023), and adolescence (Kirk et al., 2023).

However, as patterns of psychopathology are well established by preschool age at levels equivalent to older ages (Dougherty et al., 2015), to prevent impairing symptoms, identification of atypical irritability should occur younger, during the neurodevelopmental vulnerability phase of psychopathology. This requires expansion of the developmental specification framework to toddlerhood. During the crucial transition to toddlerhood, children's independent mobility and cognitive and language capabilities dramatically increase as well as their abilities (and parental expectations) to regulate their emotions (Calkins & Fox, 2002); yet these skills are less consolidated than they are at preschool age. With these developmental challenges come more opportunities for neurodevelopmental vulnerabilities to manifest (Hogan and Quay, 2014; Krogh‐Jespersen et al., 2021). Indeed, during the transition to toddlerhood, when regulation shifts from externally‐(e.g., parents) to more internally‐mediated, increases in irritability typically become apparent to parents, teachers, and pediatricians/clinical providers, providing opportunities for identification of transdiagnostic risk to maximize malleability to prevention. In an independent sample, we recently validated a developmentally modified version of the MAPS‐TL scale (MAPS‐TL‐IT, i.e., Infant‐Toddler) for the transition to toddlerhood (Krogh‐Jespersen et al., 2021). With this younger sample, we demonstrated the normal:abnormal spectrum of irritability at the transition to toddlerhood. Consistent with our prior work at preschool age (Wakschlag et al., 2012), we showed that markers of atypicality for irritable behaviors fall in two broad patterns: normative misbehavior displayed by most children but not at high frequency versus uncommon rare behaviors that indicate severity even occurring at low frequencies. The MAPS‐TL‐IT demonstrated test‐retest reliability and convergent validity (Krogh‐Jespersen et al., 2021). Trajectory analyses across the second year of life with the MAPS‐TL‐IT also demonstrate moderate stability (Zhang et al., in press). While this was an important advance for neurodevelopmental characterization of the full normal:abnormal spectrum of irritability, pragmatic irritability tools for this age are lacking. To our knowledge, there are currently no parsimonious empirically‐derived measures that could be used to screen for clinically salient levels of irritability at this key developmental period in real world settings (Wakschlag et al., 2022). Thus, the purpose of this article is to lay the psychometric groundwork for a MAPS‐TL‐IT clinically optimized screener to identify toddlers at heightened risk for impairing psychopathology.

2. METHODS

2.1. Sample

This study utilized data from the N = 356 infants/toddlers in the midwestern United States in the W2W Study, enriched for clinical risk by oversampling for irritability and recruited via screening, social media, ads, and flyers (for details on W2W, see Krogh‐Jespersen et al., 2021). Participants were 57% not White/Non‐Hispanic, 31% poor/near poor, and roughly evenly split on sex (sample characteristics in Table 1). Mothers and their infants participated in in‐depth, lab‐based assessments at ∼14 months old (mean age = 14.5 months, SD = 1.8), which included information on irritability (MAPS, see below) and impairment (E‐CRI and Family Life Impairment Scale (FLIS), see below). Additionally, to assess impairment (FLIS, see below), bimonthly online survey follow‐ups were conducted over the subsequent year, with an additional in‐person visit at ∼24 months old. Toddlers whose parents completed both irritability and impairment assessments at baseline were included, for an analytic sample of N = 350. COVID‐19 workplace closures and quarantine restrictions affected retention for the follow‐ups, especially for the second lab‐based assessment (55% returned for the in‐person visit), and also the bimonthly surveys, in which retention dropped (66%–88%) as COVID‐19 disruptions endured. Given this, we used estimation methods robust to high levels of attrition in analyses (see Data Analysis Plan).

TABLE 1.

Participant demographics.

All participants Meets cutoff Not meet cutoff χ2 df p
N = 350 n = 115 n = 206
Child gender 1.98 1 0.160
Females 161 (46%) 47 (41%) 101 (49%)
Males 189 (54%) 68 (59%) 105 (51%)
Race/ethnicity 6.24 4 0.182
White 146 (42%) 47 (41%) 97 (47%)
Black/African American 79 (23%) 20 (17%) 48 (23%)
Hispanic 54 (15%) 31 (27%) 43 (21%)
Other 71 (20%) 15 (13%) 14 (7%)
Parent cohabitation status 0.153 1 0.696
Living with partner 252 (95%) 91 (95%) 161 (96%)
Not living with partner 12 (5%) 5 (5%) 7 (4%)
Poverty (income:needs) 0.94 2 0.626
Not poor 219 (69%) 79 (71%) 140 (69%)
Near poor 38 (12%) 15 (13%) 23 (11%)
Poor 59 (19%) 18 (16%) 41 (20%)
Mean (SD) Mean (SD) t df p
Child's age at baseline (in months) 14.5 (1.8) 14.0 (1.7) 2.46 221.67 0.015
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Note: Numbers may vary across categories due to missing data. Percentages reflect proportions within available data. White and Black/African American categories are non‐Hispanic. N = 4 participants identified as Black and Hispanic, while the remainder of Hispanic participants identified as White or did not specify race. “Other” race/ethnicity includes multiracial participants and participants who identified as Asian, Native Hawaiian/Pacific Islander, Native American/Alaskan Native.

Abbreviations: df, degrees of freedom; SD, standard deviation.

2.2. Measures

2.2.1. Irritability

The MAPS‐TL‐IT (Krogh‐Jespersen et al., 2021) was used to characterize irritable behaviors and mood, including context, expression, and qualitative features, for example, “have a temper tantrum until exhausted”, “act grumpy”. To reduce bias that may occur when using subjective rating scales, the MAPS‐TL uses an objective frequency rating scale, that is, times behavior exhibited over the past month (0 = never, 1 = once, 2 = 1–3 days/week, 3 = 4–6 days/week, 4 = daily, 5 = multiple times/day).

2.2.2. Impairment

Taking impairment into account is crucial for identifying clinical salience at in young children because of the overlap of the normative misbehaviors of this period, such as tantrums, and diagnostic and statistical manual of mental disorders (DSM) symptoms (Wakschlag et al., 2020). We assessed irritability‐related impairment in two ways: (1) Early Childhood Irritability‐Related Impairment Interview (E‐CRI; Wakschlag et al., 2020) and (2) Family Life Impairment Scale (FLIS; Mian et al., 2018). The E‐CRI is a semi‐structured parent interview that captures whether children's irritable mood or behaviors interfere with social and developmental functioning across contexts (e.g., “going to child‐friendly places such as playground or library”, “playing on his/her own”); and has been shown to be reliable and valid using two independent samples of young children (Wakschlag et al., 2020). The FLIS is a parent‐report questionnaire that measures functional impairment in child, family, and childcare domains (baseline Cronbach's α = 0.88) (Mian et al., 2018; Wakschlag et al., 2020). For the W2W Study, it was modified to probe impairment specific to irritability. Family Life Impairment Scale scores were used in this study both as binary (Aim 1) and continuous (Aim 3) outcomes (see Analytic Plan).

2.3. Analytic Plan

Using the empirically‐driven data reduction and cutoff derivation approach as described in Wiggins et al. (2018) to maximize validity in a prior independent sample of preschoolers, our W2W analyses derived a brief version of the MAPS‐TL‐IT (i.e., clinically optimized screener) with a cutoff at which such behaviors should “spark worry” about current and future impairment. This was accomplished in three steps: First, we determined the irritable behaviors most informative for discriminating concurrent impairment on the FLIS at baseline. Second, we derived an empirically‐based cutoff for this clinically optimized screener to concurrent impairment as measured by the E‐CRI interview. For this second step we used the early childhood irritability‐related impairment to avoid circularity with the first step where the FLIS was used. Third, we evaluated the predictive value of this clinically optimized screener for trajectories of FLIS impairment from 14 to 26 months over the next year as a metric of ‘when to worry’ about toddler irritability.

Step 1

Empirically derive a clinically optimized screener by determining MAPS‐TL‐IT items those items most informative for discriminating concurrent FLIS impairment at the transition to toddlerhood.

To accomplish this, we used stepwise logistic regression, using forward entry with the likelihood ratio comparison of models in international business machines statistical package for the social sciences v. 27 software (https://www.ibm.com/products/spss‐statistics) to determine the relative discriminative value of the 30 individual MAPS‐TL‐IT irritability items in relation to the concurrent FLIS impairment at baseline. To minimize overidentification of clinically significant irritability, as demonstrated in prior work (Wiggins et al., 2018, 2021), we required impairment endorsed in at least two of the family, child, or childcare domains. This indicator of pervasive impairment was coded as 1 = impairment in 2 or more domains versus 0 = impairment in less than 2 domains. This algorithm identified the irritable behaviors most uniquely associated with pervasive (i.e., cross‐domain), concurrent impairment. As a supplemental analysis for cross‐validation, we generated 10 random subsamples comprising 90% of the dataset in each subsample. The stepwise logistic regression was repeated on each of these subsamples to examine whether the same items as in the main results were identified.

Step 2

Derive an empirically‐based cutoff for the MAPS‐TL‐IT clinically optimized screener in relation to concurrent E‐CRI impairment.

As in Wiggins et al. (2018) (as well as this issue's Hirsch et al., 2023; Alam et al., 2023; Kirk et al., 2023), we summed the items in the clinically optimized screener and derived a cutoff for the score using a Receiver Operating Characteristics (ROC) curve with the total score as the test variable and impairment (dichotomized as any impairment endorsed in mood or behavior, given the greater sensitivity of the E‐CRI (Wakschlag et al., 2020)) as the state variable. Area under the curve is considered excellent at 0.8 and above, good from 0.7 to 0.8, fair from 0.6 to 0.7, and no better than chance at 0.5 (Pencina et al., 2008). Youden's index was used to determine the cutoff with the maximum sensitivity and specificity for the clinically optimized screener. We then statistically compared children meeting versus not meeting cutoff on sociodemographic characteristics (child sex, race/ethnicity, poverty status, age, parent cohabitation status).

Step 3

Evaluate the predictive value of the MAPS‐TL‐IT clinically optimized screener for trajectories of FLIS impairment across the second year of life.

We utilized a two‐part analytic approach: First, to establish trajectories of impairment, we used latent class growth modeling to identify unobserved but distinct groups of children based on how their impairment changed over 7 bimonthly time points in the year‐long period subsequent to the baseline irritability assessment. Family Life Impairment Scale child and family impairment were averaged and included as a continuous variable. (Childcare impairment was excluded from the average as not all children were in childcare.) Models with 1 through 4 classes were estimated and multiple fit indices, including Bayesian Information (BIC) and Akaike Information (AIC) Criteria, entropy, Vuong‐Lo‐Mendell‐Rubin and Lo‐Mendell‐Rubin Likelihood Ratio Tests (VLMR LRT; LMR LRT) (Chen et al., 2017), were comprehensively considered to identify the optimum number of groups. All models were executed with 5000 random starts to avoid local maxima. Latent class growth analyses were conducted in Mplus 8 statistical software (Muthen, 2017) because Mplus uses the expectation maximization algorithm to obtain maximum likelihood estimates with robust standard errors, the preferred method for data missing at random. For the second part, after we identified impairment trajectory groups, we then used logistic regression to calculate the odds that meeting versus not meeting the clinically optimized screener cutoff (identified in Aim 2) was associated with impairment trajectory group membership, adjusted for sociodemographic factors (child sex, race/ethnicity [white non‐Hispanic vs. not], poverty status based on income‐to‐needs ratio, and age at baseline). Established guidelines suggest variance explained (r 2) of 2% as small, 13% as medium, and 26% as large (Cohen, 1988). Confidence intervals (CI) indicate 95% levels.

3. RESULTS

Step 1

Empirically derive a clinically optimized screener by determining MAPS‐TL‐IT items those items most informative for discriminating concurrent FLIS impairment at the transition to toddlerhood.

The final stepwise logistic regression model identified 5 of 30 items of MAPS‐TL‐IT irritability items as uniquely predicting FLIS cross‐domain impairment: “become frustrated about small things,” “hit, bite or kick during tantrum,” “trouble cheering up when grumpy,” “act grumpy during fun activities,” and “temper tantrum in public” (Table 2). Odds ratios ranged from 1.54 to 1.97, indicating that with every unit increase in the frequency scale for each individual behavior, odds of having cross‐domain impairment increased by a factor of approximately one‐and‐a‐half to two times. The final model, with the total 5 items, explained 37.3% of the variance in cross‐domain impairment and was a good fit to the data (ꭓ2 = 98.563, df = 5, p < 0.001). Cross‐validation replicated each item across multiple iterations (Table S2). These five items were summed (mean = 4.11, SD = 3.36, minimum = 0, maximum = 22) to create the infant/toddler MAPS‐TL clinically optimized score for the pragmatic version used in Steps 2 and 3.

TABLE 2.

Odds ratios and change in chi‐square resulting in final stepwise regression model.

Behavior Odds ratio (final model) Confidence interval (95%) p (OR) Step added Δꭓ2 p (Δꭓ2)
Lower bound Higher bound
Become frustrated about small things 1.54 1.15 2.07 0.004 1 48.22 <0.001
Hit, bite, or kick during a temper tantrum 1.75 1.20 2.54 0.003 2 23.93 <0.001
Have trouble cheering up when grumpy 1.87 1.00 3.47 0.049 3 13.31 <0.001
Act grumpy during fun activities 1.83 1.06 3.16 0.031 4 8.97 0.003
Have a temper tantrum when you were out in public with him/her 1.97 1.28 3.03 0.002 5 4.14 0.042
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Note: Δꭓ2 = change in chi‐square when adding that behavior to the model consecutively in steps. Odds ratios represent final values calculated with all 5 behaviors in the model.

Step 2

Derive an empirically‐based cutoff for the MAPS‐TL‐IT clinically optimized screener in relation to concurrent E‐CRI impairment.

Area under the curve = 0.755 (p < 0.05) for the ROC analysis (Figure 1) indicated good classification accuracy of the MAPS‐TL‐IT clinically optimized screener for E‐CRI impairment. A cutoff of 5 on the total score maximized sensitivity (71.4%, CI = 55.4–84.3%) and specificity (70.6%, CI = 64.8–76.0%) for concurrent impairment, demonstrating acceptable rates of true positives and true negatives. In this irritability enriched sample, 35.8% scored above and 64.2% scored below the cutoff of 5, similar to prior prevalence rates of clinically significant irritability in preschool age (Wiggins et al., 2018). A score of 5 translated to demonstrating all of these behaviors (low frustration tolerance; aggressive tantrums; intransigent and inappropriate grumpy mood; tantrum in developmentally unexpectable contexts) at least once in the past month (i.e., a score of 1 in each category). Alternatively, if the full range of behaviors was not displayed, then frequency in at least one of the other behavior categories needed to increase to at least weekly (i.e., a score of 2) for a child to be identified with clinically significant irritability. In practice, as would be expected at this young age, very few children (<1%) showed low levels of all behaviors (score of 1 across all items) (see Table S1, available online). In fact, >99% of children showed low frustration tolerance at least 1–3 days/week (i.e., a score of 2 or greater on this item). Children who met versus did not meet cutoff did not differ on race/ethnicity, gender, poverty status, or parent cohabitation status (Table 1). Participants who did versus did not meet cutoff were slightly older, by about 2 weeks, although this difference was negligible in real‐world terms (Table 1). Table S1 (available online) is an interactive table of the frequencies of score combinations on the five items for children who met cutoff.

FIGURE 1.

FIGURE 1

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Receiver Operator Characteristic curve for Multidimensional Assessment Profiles Temper Loss (MAPS‐TL) clinically optimized screener total score detecting E‐CRI impairment. Arrow indicates maximum sensitivity and specificity.

Step 3

Evaluate the predictive value of the MAPS‐TL‐IT clinically optimized screener for trajectories of FLIS impairment across the second year of life.

For the first step to determine impairment trajectory classes, we comprehensively considered fit indices across models with 1 to 4 classes (Table S3). BIC and AIC decreased with the addition of more classes, indicating more classes better fit the data. However, VLMR‐LRT and LMR‐LRT supported 2 classes. Additionally, entropy was highest for 2 classes (0.91). Therefore, the 2‐class model was chosen as best‐fitting. Classes comprised one group of children (80%, n = 262) with consistently low impairment (intercept = 0.29, CI = 0.24–0.34, p < 0.001) across ages ∼14–26 months and a second group (20%, n = 66) with persistently elevated impairment (intercept = 0.92, CI = 0.74–1.01, p < 0.001) across that age period. The persistently elevated impairment group increased in impairment (slope = 0.032, CI = −0.014–0.078) faster than the low impairment group (slope = −0.003, CI = −0.012–0.005; p < 0.05 for the difference in slopes) (Figure 2). Logistic regression indicated that children at or above the cutoff for the MAPS‐TL clinically optimized screener at baseline were 4.37 times (CI = 2.40–7.97, p < 0.001) more likely to be in the persistently elevated impairment class, adjusted for sociodemographic characteristics (Figure 3). Indeed, the screener total score accounted for 13.4% of the variance in impairment trajectory class membership (Nagelkerke R 2 ; Δꭓ2 = 24.44, df = 1, p < 0.001).

FIGURE 2.

FIGURE 2

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Trajectories of impairment generated by latent class growth analysis. Family Life Impairment Scale (FLIS) scores. High impairment class: Intercept = 0.917, Confidence intervals (CI) = 0.738–1.095 p < 0.001; Slope = 0.032, CI = −0.014–0.078, p = 0.072. Low impairment class: Intercept = 0.294, CI = 0.243–0.343, p < 0.001; Slope = −0.003, CI = −0.012–0.005, p = 0.307.

FIGURE 3.

FIGURE 3

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Proportions of impairment trajectory groups that meet irritability cutoff on the Multidimensional Assessment Profiles Temper Loss (MAPS‐TL) clinically optimized screener. Illustrative graph unadjusted for sociodemographics. Adjusted odds ratio indicates a 4.37 fold increase in likelihood of being in the sustained high impairment group if a child meets the empirically derived cutoff.

4. DISCUSSION

To address the developmental origins of the current pediatric mental health crisis, a far‐reaching, earlier identification and prevention approach is needed, implemented with scalable and transdiagnostic pragmatic tools. Generating pragmatic methods that are feasible for implementation in real‐world settings is key to closing the research‐to‐practice gap (Wakschlag et al., 2022; Walkup et al., 2017). Indeed, a translational mindset involves viewing assessment outside a rarified research context and instead as broadly implementable in resource‐limited settings without specialized supports (Wakschlag et al., 2022). This translational mindset motivated the research presented here, which offers the first pragmatically oriented approach to identify irritability‐related impairing transdiagnostic patterns this early in development. Capitalizing on malleability at peak levels of neurodevelopmental plasticity, before clinical disorders take hold, is crucial to head off the escalation of early onset mental health problems in youths. As psychometric groundwork for the development of clinically feasible transdiagnostic tools, our results are a first step to validate an approach for identifying mental health risk for impairing internalizing/externalizing problems based on elevated irritability, at an age (transition to toddlerhood) substantially earlier than prior work. Indeed, we showed that with as little as five survey items, it is possible to identify clinically significant irritability in toddlers in close proximity to their first birthdays. This elevated irritability, in turn, quadruples the risk for sustained impairment over the second year of life. To put this into context, the odds ratio for low‐dose aspirin reducing incidence of cardiovascular disease events is 1.14 yet based on this relatively lower odds ratio (vs. the adjusted odds ratio of 4.37 identified for irritability), sweeping intervention as standard of care has been implemented internationally (Force et al., 2022). This points to the importance of future validation in population level samples and clinical implementation studies will be necessary next steps.

To our knowledge, this MAPS‐TL‐IT clinically optimized screener is the first pragmatic, transdiagnostic mental health screener, reflecting developmentally based translation of the robust science base on irritability. This is an important step toward clinical feasibility (Klein et al., 2021; Leibenluft & Kircanski, 2021). Our findings add to the armamentarium of other developmentally based tools for early mental health risk identification (Briggs‐Gowan et al., 2004; Sheldrick et al., 2013). The MAPS‐TL‐IT clinically optimized screener adds to the existing evidence‐based toolkit via its brief transdiagnostic approach derived from the full normal:abnormal irritability spectrum within developmental context. This work opens a pathway to take early transdiagnostic mental health screening to scale within primary care pediatrics. In this trusted, non‐stigmatized setting, behavioral health screening is an essential part of routine care, young children are monitored frequently, and the majority of US children receive care (Sheldrick & Perrin, 2009; Wakschlag et al., 2019). Moreover, broadly implementing this clinical identification approach in primary care also has the potential to reduce early mental health inequities, by providing an empirically‐based, efficient broad‐based mental health risk screener for practical use. Having an empirically and developmentally anchored transdiagnostic screener can reduce pediatricians' decisional uncertainty associated with differentiation of normative versus clinically salient variation in early childhood. In turn, this may reduce cognitive load for clinicians, decreasing the likelihood of reliance on social stereotyping for early mental health risk decision making (Van Ryn & Fu, 2003; Wakschlag et al., 2022).

These results extend our prior work developing pragmatic clinical screening for preschool age (Wiggins et al., 2018) and additional work in this issue validating the MAPS‐TL through early school age (Hirsch et al., 2023), preadolescence (Alam et al., 2023) and adolescence (Kirk et al., 2023). Our results underscore that a “wait and see” approach, born of the assumption that atypical irritability patterns are not detectable at very young ages, may miss important opportunities for preventive intervention at the height of neuroplasticity. In broad strokes, the behaviors that we found to be most informative for clinical identification at the transition to toddlerhood paralleled the items that we had previously found for preschool age children (low frustration tolerance and dysregulated tantrums). The ubiquity of low frustration tolerance in our sample bolsters the idea that a dispositional tendency toward frequent frustration may be a necessary foundation for clinically significant irritability, consistent with prior work (Wiggins et al., 2018, 2021; Hirsch et al., 2023, Alam et al., 2023, Kirk et al., 2023). Moreover, virtually all children who had clinically significant irritability showed a combination of low frustration tolerance, plus endorsement, even if rarely, of at least one of the other behaviors that are less common and more severe (aggressive tantrums; intransigent or inappropriate grumpy mood; tantrum in developmentally unexpectable contexts). This is in line with our work in preschoolers and beyond (Wiggins et al., 2018, 2021; Hirsch et al., 2023, Alam et al., 2023, Kirk et al., 2023). Together, these point to the conclusion that a combination of elevated frequency of common behaviors (particularly low frustration tolerance) and the presence, even at low frequency, of pathognomonic, uncommon behaviors is best to “loop in” children of concern and “filter out” children who may not need intervention.

Despite similarities in broad strokes, the differences in infant‐toddler versus older ages items identified as most informative for clinical discrimination across a relatively short window in early childhood underscores the importance of developmentally specified criteria for accurate clinical identification. Yet, at present, the DSM‐5 (and most standardized scales) uses similar diagnostic criteria for wide age swaths (American Psychiatric Association, 2013). For example, we have previously shown that disruptive mood dysregulation disorder, which encapsulates severe, chronic irritability, can be identified within preschool age with developmentally specified criteria (Wiggins et al., 2021). Our work here suggests that future iterations of the DSM may increase developmental sensitivity of assessment by accounting for variation in phenotypes within developmental context.

4.1. Limitations

This work has several limitations. First, we rely on mother report (MAPS‐TL and FLIS questionnaires and E‐CRI interview) throughout. This introduces shared method variance as all were based on maternal report, albeit through multiple methods (i.e., survey and interview). Future work incorporating standardized direct observation of irritability for example, with the Disruptive Behavior Diagnostic Observational Schedule (DB‐DOS; Wakschlag et al., 2008), may be useful. Second, whereas this younger, longitudinally characterized sample was advantageous for this initial development of the MAPS‐TL‐IT clinically optimized screener and empirically‐based cutoff for screening at the transition to toddlerhood, it will also be necessary to replicate and validate our findings in larger representative samples with more intensive clinical assessment and longer follow‐up. Third, this study was limited to a single year in early childhood. Although the second year of life is a time period of significant developmental shifts, it is possible that a longer period of follow‐up would allow us to detect decreases and increases in impairment, which we used to validate the irritability cutoff. This is consistent with emerging work showing that symptoms are more stable during this age period than previously anticipated (Zhang et al., in press). Fourth, while our community sample was important for translation to settings such as pediatric primary care, further validation within clinical samples will be necessary to detect subgroups within children at high risk. Finally, although this was intended as a first step toward application in routine practice, actual translation to clinical settings requires an integrated developmental‐implementation science approach which takes characteristics and priorities of stakeholders and settings into account as tools, measures, and other research products move from the laboratory to routine care settings (Wakschlag et al., 2022).

5. CONCLUSION AND FUTURE DIRECTIONS

This study was motivated by the need for scalable early identification tools prompted by the current pediatric mental health crisis, exacerbated by the pandemic which has been disproportionately detrimental for minoritized subgroups (Stephenson, 2021). Here, to facilitate widespread screening for transdiagnostic risk as early as possible in the clinical sequence, we applied a pragmatic approach. Our findings help to close the considerable gap in science‐to‐practice by generating transdiagnostic, developmentally‐based indicators designed to ultimately be feasible for clinical use. This work is foundational for clinical translation that may be more palatable for earlier identification than a DSM‐oriented approach, which is inconsistent with clinical presentation at young ages (Wiggins et al., 2021) and often raises concerns about overidentification and potential stigma (Wiggins & Wakschlag, 2021). Importantly, this work is a step toward putting a pragmatic tool in providers' hands that can flag “when to worry” about young children exhibiting clinically impairing irritability levels. When validated in real‐world settings, this approach must be linked to developmentally‐based parent management prevention programs, which reduce irritability and promote early self‐regulation (Roby et al., 2021; Smith et al., 2019). There is evidence that validated parent management interventions reduce irritability in young children (Barlow et al., 2013; Keefe et al., 2005; Roby et al., 2021; Smith et al., 2019), This is underscored by the role that irritability plays in the common emotional and behavioral syndromes of childhood that have their roots in early life but might not reach diagnosable levels until childhood or adolescence. Using irritability screening for indication of broad early risk for psychopathology is a critical step for prevention. This pragmatic approach is important to advance the development of a real‐world system of care designed to alter mental health risk trajectories in the initial phase of the clinical sequence when experience‐dependent neuroplasticity is most prominent.

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. Ms. Yu assisted in data analysis. Ms. Yu and Drs. Zhang, MacNeill, Norton 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 declare no conflicts of interest.

ETHICS STATEMENT

This study was approved by the Institutional Review Board of Northwestern University School of Medicine.

CONSENT

Parents gave informed parental permission for their children to participate in the study and informed consent for their own participation.

CLINICAL TRIAL REGISTRATION

This is not a clinical trial and thus does not require registration.

Supporting information

Supplementary Material S1

Click here for additional data file. (1.7MB, docx)

Table S1

Click here for additional data file. (19KB, spv)

ACKNOWLEDGMENTS

We gratefully acknowledge our W2W collaborators, especially Sheila Krogh‐Jespersen, Amelie Petitclerc, Renee Edwards and our study team for their contributions to the W2W study. The When to Worry (W2W) Study was supported by a National Institute of Mental Health grant to Dr. Wakschlag (R01MH107652).

Wiggins, J. L. , Ureña Rosario, A ., Zhang, Y. , MacNeill, L. , Yu, Q. , Norton, E. , Smith, J. D. , & Wakschlag, L. S. (2023). Advancing earlier transdiagnostic identification of mental health risk: A pragmatic approach at the transition to toddlerhood. International Journal of Methods in Psychiatric Research, 32(S1), e1989. 10.1002/mpr.1989

DATA AVAILABILITY STATEMENT

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

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material S1

Click here for additional data file. (1.7MB, docx)

Table S1

Click here for additional data file. (19KB, spv)

Data Availability Statement

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

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