Validation of the Temper Outbursts/Irritability-2: A Two-Item Screener for Temper Outbursts and Irritability in Youth

Abstract

Objective:

Irritability and temper outbursts are common presenting concerns in pediatric mental health settings, but systematic monitoring can be difficult to sustain with broad, repeated assessment batteries. This study evaluated the temper outbursts/irritability-2 (TOI-2), an ultra-brief, two-item screener assessing temper outbursts and frequently irritable mood in youth.

Methods:

Participants were 1515 youth aged 5–17 years (M = 11.80, SD = 3.60) referred to an outpatient child psychiatry clinic. Female caregivers (90.4% biological mothers) completed the TOI-2 and criterion measures at intake. Convergent and discriminant validity were assessed via correlations with the Affective Reactivity Index (ARI), administered with a current-state timeframe, oppositional defiant disorder (ODD) symptom dimensions, attention-deficit/hyperactivity disorder, conduct disorder (CD), depression, and anxiety. Screening accuracy was evaluated using receiver operating characteristic analysis, with elevated irritability defined as ARI ≥ 4. Clinical utility was examined using screen-positive and screen-negative comparisons and known-group analyses.

Results:

The TOI-2 showed strong convergence with the ARI and ODD-Irritability symptoms (rs = 0.82). Its association with ODD-Irritability was significantly stronger than with ODD-Behavioral symptoms (r = 0.70; p < 0.001), supporting relative specificity to irritability within the broader disruptive behavior spectrum. ROC analysis indicated excellent classification accuracy, area under the curve = 0.91. Cut scores of ≥2.5 and ≥3.0 both optimized overall performance, Youden’s J = 0.66. A threshold of ≥3.0 is recommended for specialty-clinic triage, whereas ≥2.5 may be preferable when maximizing case detection is the priority. Youth who screened positive showed greater symptom severity and poorer adjustment across clinical domains. Known-groups analyses showed the largest TOI-2 elevations among youth meeting symptom-count thresholds for ODD and CD.

Conclusions:

The TOI-2 is a psychometrically sound, ultra-brief screener for clinically significant irritability in youth. Positive screens should prompt more comprehensive clinical assessment of irritability, impairment, disruptive behavior, mood symptoms, and treatment needs.