European Child & Adolescent Psychiatry

, Volume 28, Issue 5, pp 667–683 | Cite as

Suicidal behaviors and irritability in children and adolescents: a systematic review of the nature and mechanisms of the association

  • Xavier BenarousEmail author
  • Angèle Consoli
  • David Cohen
  • Johanne Renaud
  • Hélène Lahaye
  • Jean-Marc Guilé
Original Contribution


While many psychiatric disorders are associated with an increased risk for suicidal behaviors (SB) in children and adolescents, a few studies have explored the role of clinical symptoms based on a dimensional approach. Irritability is seen as a marker, a general psychopathology, and a symptom of both externalizing and internalizing disorders. In this review, we are interested in determining whether and how irritability can predict SB in youth. First, we reviewed consistencies and variation in the literature linking irritability to suicidal ideation (SI) and suicide attempt (SA). Second, based on the available models, we proposed specific mechanistic pathways, whereby irritability may modulate the risk for SB. Irritability has been found associated with SB both in cross-sectional and in longitudinal studies. The relation is consistent in different settings (i.e., general population and clinical settings) and across psychiatric disorders. The association is reduced but persists after adjusting for psychiatric disorder, including depression. On one hand, irritability constitutes a risk factor for SI via the onset of internalized disorder. On the other hand, irritable youth may be more prone to attempt suicide when experiencing SI. The measures for irritability were heterogeneous. A limited number of studies were designed to explore the role of mediators and/or moderators. Recognizing irritability in children and adolescents is a key issue with regards to suicide prevention.


Irritability Trait anger Rage Disruptive mood dysregulation disorder Emotional dysregulation Suicidal behavior Suicidal ideation Suicide attempt 


Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.


  1. 1.
    Kolves K, De Leo D (2014) Suicide rates in children aged 10-14 years worldwide: changes in the past two decades. Br J Psychiatry 205:283–285CrossRefPubMedGoogle Scholar
  2. 2.
    Turecki G, Brent DA (2016) Suicide and suicidal behaviour. Lancet 387:1227–1239CrossRefPubMedGoogle Scholar
  3. 3.
    Stallard P (2016) Suicide rates in children and young people increase. Lancet 387:1618CrossRefPubMedGoogle Scholar
  4. 4.
    Shain B, AAP Committe on Adolescence (2016) Suicide and Suicide Attempts in Adolescents. Pediatrics 138:e20161420CrossRefPubMedGoogle Scholar
  5. 5.
    Balazs J, Kereszteny A (2017) Attention-deficit/hyperactivity disorder and suicide: a systematic review. World J Psychiatry 7:44–59CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hill RM, Castellanos D, Pettit JW (2011) Suicide-related behaviors and anxiety in children and adolescents: a review. Clin Psychol Rev 31:1133–1144CrossRefPubMedGoogle Scholar
  7. 7.
    Breton JJ, Labelle R, Berthiaume C, Royer C, St-Georges M, Ricard D, Abadie P, Gerardin P, Cohen D, Guile JM (2015) Protective factors against depression and suicidal behaviour in adolescence. Can J Psychiatry 60:S5–s15PubMedPubMedCentralGoogle Scholar
  8. 8.
    Brezo J, Paris J, Barker ED, Tremblay R, Vitaro F, Zoccolillo M, Hebert M, Turecki G (2007) Natural history of suicidal behaviors in a population-based sample of young adults. Psychol Med 37:1563–1574CrossRefPubMedGoogle Scholar
  9. 9.
    Mirkovic B, Labelle R, Guile JM, Belloncle V, Bodeau N, Knafo A, Condat A, Bapt-Cazalets N, Marguet C, Breton JJ, Cohen D, Gerardin P (2015) Coping skills among adolescent suicide attempters: results of a multisite study. Can J Psychiatry 60:S37–45CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Hoertel N, Franco S, Wall MM, Oquendo MA, Kerridge BT, Limosin F, Blanco C (2015) Mental disorders and risk of suicide attempt: a national prospective study. Mol Psychiatry 20:718–726CrossRefGoogle Scholar
  11. 11.
    Leibenluft E, Stoddard J (2013) The developmental psychopathology of irritability. Dev Psychopathol 25:1473–1487CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. Author, Washington, DCGoogle Scholar
  13. 13.
    Stringaris A, Vidal-Ribas P, Brotman MA, Leibenluft E (2018) Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. J Child Psychol Psychiatry 59:721–739CrossRefPubMedGoogle Scholar
  14. 14.
    Althoff RR, Crehan ET, He JP, Burstein M, Hudziak JJ, Merikangas KR (2016) Disruptive mood dysregulation disorder at ages 13–18: results from the national comorbidity survey-adolescent supplement. J Child Adolesc Psychopharmacol 26:107–113CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, Leibenluft E (2006) Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry 60:991–997CrossRefPubMedGoogle Scholar
  16. 16.
    Leibenluft E, Cohen P, Gorrindo T, Brook JS, Pine DS (2006) Chronic versus episodic irritability in youth: a community-based, longitudinal study of clinical and diagnostic associations. J Child Adolesc Psychopharmacol 16:456–466CrossRefPubMedGoogle Scholar
  17. 17.
    Stringaris A, Maughan B, Copeland WS, Costello EJ, Angold A (2013) Irritable mood as a symptom of depression in youth: prevalence, developmental, and clinical correlates in the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry 52:831–840CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Apter A, Bleich A, King RA, Kron S, Fluch A, Kotler M, Cohen DJ (1993) Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry 50:138–142CrossRefPubMedGoogle Scholar
  19. 19.
    Borst SR, Noam GG (1993) Developmental psychopathology in suicidal and nonsuicidal adolescent girls. J Am Acad Child Adolesc Psychiatry 32:501–508CrossRefPubMedGoogle Scholar
  20. 20.
    Shaffer D (1974) Suicide in childhood and early adolescence. J Child Psychol Psychiatry 15:275–291CrossRefPubMedGoogle Scholar
  21. 21.
    Hoberman HM, Garfinkel BD (1988) Completed suicide in children and adolescents. J Am Acad Child Adolesc Psychiatry 27:689–695CrossRefPubMedGoogle Scholar
  22. 22.
    Freuchen A, Kjelsberg E, Lundervold AJ, Groholt B (2012) Differences between children and adolescents who commit suicide and their peers: a psychological autopsy of suicide victims compared to accident victims and a community sample. Child Adolesc Psychiatry Ment Health 6:1CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Vidal-Ribas P, Brotman MA, Valdivieso I, Leibenluft E, Stringaris A (2016) The status of irritability in psychiatry: a conceptual and quantitative review. J Am Acad Child Adolesc Psychiatry 55:556–570CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Toohey MJ, DiGiuseppe R (2017) Defining and measuring irritability: construct clarification and differentiation. Clin Psychol Rev 53:93–108CrossRefPubMedGoogle Scholar
  25. 25.
    Berkowitz L (1974) Some determinants of impulsive aggression: role of mediated associations with reinforcements for aggression. Psychol Rev 81:165–176CrossRefPubMedGoogle Scholar
  26. 26.
    Dodge KA, Coie JD (1987) Social-information-processing factors in reactive and proactive aggression in children’s peer groups. J Pers Soc Psychol 53:1146–1158CrossRefPubMedGoogle Scholar
  27. 27.
    Stanford MS, Houston RJ, Mathias CW, Villemarette-Pittman NR, Helfritz LE, Conklin SM (2003) Characterizing aggressive behavior. Assessment 10:183–190CrossRefPubMedGoogle Scholar
  28. 28.
    Posner K, Oquendo MA, Gould M, Stanley B, Davies M (2007) Columbia Classification Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. Am J Psychiatry 164:1035–1043CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Pickles A, Aglan A, Collishaw S, Messer J, Rutter M, Maughan B (2010) Predictors of suicidality across the life span: the Isle of Wight study. Psychol Med 40:1453–1466CrossRefPubMedGoogle Scholar
  30. 30.
    Park YJ, Ryu H, Han KS, Kwon JH, Kim HK, Kang HC, Yoon JW, Cheon SH, Shin H (2010) Anger, anger expression, and suicidal ideation in Korean adolescents. Arch Psychiatr Nurs 24:168–177CrossRefPubMedGoogle Scholar
  31. 31.
    Zhang P, Roberts RE, Liu Z, Meng X, Tang J, Sun L, Yu Y (2012) Hostility, physical aggression and trait anger as predictors for suicidal behavior in Chinese adolescents: a school-based study. PLoS One 7:e31044CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Sigfusdottir ID, Asgeirsdottir BB, Gudjonsson GH, Sigurdsson JF (2013) Suicidal ideations and attempts among adolescents subjected to childhood sexual abuse and family conflict/violence: the mediating role of anger and depressed mood. J Adolesc 36:1227–1236CrossRefPubMedGoogle Scholar
  33. 33.
    Althoff RR, Rettew DC, Faraone SV, Boomsma DI, Hudziak JJ (2006) Latent class analysis shows strong heritability of the child behavior checklist-juvenile bipolar phenotype. Biol Psychiatry 60:903–911CrossRefPubMedGoogle Scholar
  34. 34.
    Volk HE, Todd RD (2007) Does the Child Behavior Checklist juvenile bipolar disorder phenotype identify bipolar disorder? Biol Psychiatry 62:115–120CrossRefPubMedGoogle Scholar
  35. 35.
    Althoff RR, Verhulst F, Rettew DC, Hudziak JJ, van der Ende J (2010) Adult outcomes of childhood dysregulation: a 14-year follow-up study. J Am Acad Child Adolesc Psychiatry 49:1105–1116.e1101PubMedPubMedCentralGoogle Scholar
  36. 36.
    Holtmann M, Buchmann AF, Esser G, Schmidt MH, Banaschewski T, Laucht M (2011) The Child Behavior Checklist-Dysregulation Profile predicts substance use, suicidality, and functional impairment: a longitudinal analysis. J Child Psychol Psychiatry 52:139–147CrossRefPubMedGoogle Scholar
  37. 37.
    Mbekou V, Gignac M, MacNeil S, Mackay P, Renaud J (2014) The CBCL dysregulated profile: an indicator of pediatric bipolar disorder or of psychopathology severity? J Affect Disord 155:299–302CrossRefPubMedGoogle Scholar
  38. 38.
    Withers LE, Kaplan DW (1987) Adolescents who attempt suicide: a retrospective clinical chart review of hospitalized patients. Prof Psychol Res Pract 18:391–393CrossRefGoogle Scholar
  39. 39.
    Myers K, McCauley E, Calderon R, Treder R (1991) The 3-year longitudinal course of suicidality and predictive factors for subsequent suicidality in youths with major depressive disorder. J Am Acad Child Adolesc Psychiatry 30:804–810PubMedGoogle Scholar
  40. 40.
    Brent DA, Johnson B, Bartle S, Bridge J, Rather C, Matta J, Connolly J, Constantine D (1993) Personality disorder, tendency to impulsive violence, and suicidal behavior in adolescents. J Am Acad Child Adolesc Psychiatry 32:69–75CrossRefPubMedGoogle Scholar
  41. 41.
    Goldston DB, Daniel S, Reboussin DM, Kelley A, Ievers C, Brunstetter R (1996) First-time suicide attempters, repeat attempters, and previous attempters on an adolescent inpatient psychiatry unit. J Am Acad Child Adolesc Psychiatry 35:631–639CrossRefPubMedGoogle Scholar
  42. 42.
    Esposito C, Spirito A, Boergers J, Donaldson D (2003) Affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts. Suicide Life Threat Behav 33:389–399CrossRefPubMedGoogle Scholar
  43. 43.
    Frazier EA, Liu RT, Massing-Schaffer M, Hunt J, Wolff J, Spirito A (2016) Adolescent but not parent report of irritability is related to suicidal ideation in psychiatrically hospitalized adolescents. Arch Suicide Res 20:280–289CrossRefPubMedGoogle Scholar
  44. 44.
    Bodzy ME, Barreto SJ, Swenson LP, Liguori G, Costea G (2016) Self-Reported psychopathology, trauma symptoms, and emotion coping among child suicide attempters and ideators: an exploratory study of young children. Arch Suicide Res 20:160–175CrossRefPubMedGoogle Scholar
  45. 45.
    Daniel SS, Goldston DB, Erkanli A, Franklin JC, Mayfield AM (2009) Trait anger, anger expression, and suicide attempts among adolescents and young adults: a prospective study. J Clin Child Adolesc Psychol 38:661–671CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Algorta GP, Youngstrom EA, Frazier TW, Freeman AJ, Youngstrom JK, Findling RL (2011) Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation? Bipolar Disord 13:76–86CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Goldstein TR, Ha W, Axelson DA, Goldstein BI, Liao F, Gill MK, Ryan ND, Yen S, Hunt J, Hower H, Keller M, Strober M, Birmaher B (2012) Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Arch Gen Psychiatry 69:1113–1122CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Greening L, Stoppelbein L, Luebbe A, Fite PJ (2010) Aggression and the risk for suicidal behaviors among children. Suicide Life Threat Behav 40:337–345CrossRefPubMedGoogle Scholar
  49. 49.
    Horesh N, Orbach I, Gothelf D, Efrati M, Apter A (2003) Comparison of the suicidal behavior of adolescent inpatients with borderline personality disorder and major depression. J Nerv Ment Dis 191:582–588CrossRefPubMedGoogle Scholar
  50. 50.
    Aebi M, Barra S, Bessler C, Steinhausen HC, Walitza S, Plattner B (2016) Oppositional defiant disorder dimensions and subtypes among detained male adolescent offenders. J Child Psychol Psychiatry 57:729–736CrossRefPubMedGoogle Scholar
  51. 51.
    Okado Y, Bierman KL (2015) Differential risk for late adolescent conduct problems and mood dysregulation among children with early externalizing behavior problems. J Abnorm Child Psychol 43:735–747CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Fite PJ, Stoppelbein L, Greening L (2009) Proactive and reactive aggression in a child psychiatric inpatient population. J Clin Child Adolesc Psychol 38:199–205CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Conner KR, Meldrum S, Wieczorek WF, Duberstein PR, Welte JW (2004) The association of irritability and impulsivity with suicidal ideation among 15- to 20-year-old males. Suicide Life Threat Behav 34:363–373CrossRefPubMedGoogle Scholar
  54. 54.
    McKeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL (1998) Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. J Am Acad Child Adolesc Psychiatry 37:612–619CrossRefPubMedGoogle Scholar
  55. 55.
    Mann JJ, Waternaux C, Haas GL, Malone KM (1999) Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189PubMedGoogle Scholar
  56. 56.
    Sourander A, Helstela L, Haavisto A, Bergroth L (2001) Suicidal thoughts and attempts among adolescents: a longitudinal 8-year follow-up study. J Affect Disord 63:59–66CrossRefPubMedGoogle Scholar
  57. 57.
    Brent DA, Bridge J, Johnson BA, Connolly J (1996) Suicidal behavior runs in families. A controlled family study of adolescent suicide victims. Arch Gen Psychiatry 53:1145–1152CrossRefPubMedGoogle Scholar
  58. 58.
    Brent DA, Oquendo M, Birmaher B, Greenhill L, Kolko D, Stanley B, Zelazny J, Brodsky B, Firinciogullari S, Ellis SP, Mann JJ (2003) Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior. Am J Psychiatry 160:1486–1493CrossRefPubMedGoogle Scholar
  59. 59.
    Brent DA, Oquendo M, Birmaher B, Greenhill L, Kolko D, Stanley B, Zelazny J, Brodsky B, Melhem N, Ellis SP, Mann JJ (2004) Familial transmission of mood disorders: convergence and divergence with transmission of suicidal behavior. J Am Acad Child Adolesc Psychiatry 43:1259–1266CrossRefPubMedGoogle Scholar
  60. 60.
    Melhem NM, Brent DA, Ziegler M, Iyengar S, Kolko D, Oquendo M, Birmaher B, Burke A, Zelazny J, Stanley B, Mann JJ (2007) Familial pathways to early-onset suicidal behavior: familial and individual antecedents of suicidal behavior. Am J Psychiatry 164:1364–1370CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Brent DA, Melhem NM, Oquendo M, Burke A, Birmaher B, Stanley B, Biernesser C, Keilp J, Kolko D, Ellis S, Porta G, Zelazny J, Iyengar S, Mann JJ (2015) Familial pathways to early-onset suicide attempt: a 5.6-year prospective study. JAMA Psychiatry 72:160–168CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    McGirr A, Alda M, Seguin M, Cabot S, Lesage A, Turecki G (2009) Familial aggregation of suicide explained by cluster B traits: a three-group family study of suicide controlling for major depressive disorder. Am J Psychiatry 166:1124–1134CrossRefPubMedGoogle Scholar
  63. 63.
    Wakschlag LS, Briggs-Gowan MJ, Choi SW, Nichols SR, Kestler J, Burns JL, Carter AS, Henry D (2014) Advancing a multidimensional, developmental spectrum approach to preschool disruptive behavior. J Am Acad Child Adolesc Psychiatry 53(82–96):e83Google Scholar
  64. 64.
    Joiner TE Jr, Brown JS, Wingate LR (2005) The psychology and neurobiology of suicidal behavior. Annu Rev Psychol 56:287–314CrossRefPubMedGoogle Scholar
  65. 65.
    Lieb R, Bronisch T, Hofler M, Schreier A, Wittchen HU (2005) Maternal suicidality and risk of suicidality in offspring: findings from a community study. Am J Psychiatry 162:1665–1671CrossRefPubMedGoogle Scholar
  66. 66.
    Asarnow JR, Carlson GA, Guthrie D (1987) Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. J Consult Clin Psychol 55:361–366CrossRefPubMedGoogle Scholar
  67. 67.
    Roy AK, Lopes V, Klein RG (2014) Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth. Am J Psychiatry 171:918–924CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Renaud J, Berlim MT, McGirr A, Tousignant M, Turecki G (2008) Current psychiatric morbidity, aggression/impulsivity, and personality dimensions in child and adolescent suicide: a case-control study. J Affect Disord 105:221–228CrossRefPubMedGoogle Scholar
  69. 69.
    Shaw P, Stringaris A, Nigg J, Leibenluft E (2014) Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry 171:276–293CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Tourian L, LeBoeuf A, Breton JJ, Cohen D, Gignac M, Labelle R, Guile JM, Renaud J (2015) Treatment options for the cardinal symptoms of disruptive mood dysregulation disorder. J Can Acad Child Adolesc Psychiatry 24:41–54PubMedPubMedCentralGoogle Scholar
  71. 71.
    Benarous X, Consoli A, Guile JM, Garny de La Riviere S, Cohen D, Olliac B (2017) Evidence-based treatments for youths with severely dysregulated mood: a qualitative systematic review of trials for SMD and DMDD. Eur Child Adolesc Psychiatry 26:5–23CrossRefPubMedGoogle Scholar
  72. 72.
    Bridge JA, Reynolds B, McBee-Strayer SM, Sheftall AH, Ackerman J, Stevens J, Mendoza K, Campo JV, Brent DA (2015) Impulsive aggression, delay discounting, and adolescent suicide attempts: effects of current psychotropic medication use and family history of suicidal behavior. J Child Adolesc Psychopharmacol 25:114–123CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Xavier Benarous
    • 1
    • 2
    Email author
  • Angèle Consoli
    • 1
    • 3
  • David Cohen
    • 1
    • 4
  • Johanne Renaud
    • 5
    • 6
  • Hélène Lahaye
    • 7
  • Jean-Marc Guilé
    • 2
    • 6
    • 7
  1. 1.Department of Child and Adolescent PsychiatryPitié-Salpêtrière HospitalParisFrance
  2. 2.INSERM Unit U1105 Research Group for Analysis of the Multimodal Cerebral FunctionUniversity of Picardy Jules Verne (UPJV)AmiensFrance
  3. 3.GRC-15, Dimensional approach of Child and Adolescent Psychotic EpisodesPierre and Marie Curie University (UPMC)ParisFrance
  4. 4.CNRS, UMR 7222, Institute for Intelligent Systems and RoboticsSorbonne Université, UPMCParisFrance
  5. 5.Manulife Centre for Breakthroughs in Teen Depression and Suicide Prevention, Douglas Mental Health University InstituteMcGill UniversityMontrealCanada
  6. 6.Department of PsychiatryMcGill UniversityMontrealCanada
  7. 7.Child and Adolescent Psychopathology DepartmentAmiens University HospitalAmiensFrance

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