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The Checkup: Managing the Storm of a Toddler’s Tantrum

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The Checkup
By PERRI KLASS, M.D.

Pity the poor parent whose child is throwing a public tantrum. No, don’t come up with a list of excellent parenting strategies that you’re quite sure would have averted this unhappy scene. And don’t use it as an opportunity to deliver a little homily about kids today or parents today and how much better things used to be. Just pity the poor parent, offer to help if you think you can, and otherwise, give everyone some space.

We tend to focus on tantrums as bad behavior, without considering their emotional content. But responding with adult anger to what we see as misbehavior only makes things worse, and misses the question of what is going on inside the child.

“What are tantrums made of?” asked Michael Potegal, a neuroscientist and associate professor at the University of Minnesota. “The answer is anger, and what I call distress — a term I use for ‘sadness plus.’” In studies of typically developing children, anger is most likely shown at the beginning of a tantrum, and then declines, while distress behaviors tend to be pretty constant throughout. “That tantrums end with crying and not with anger is significant because kids’ crying tends to elicit parent comfort-giving,” he said. “The fact that tantrums naturally end on a distress note is probably an adaptation to reconciliation.”

Seventy-five percent of 2-year-olds will have had at least one temper tantrum in the past three months, said Dr. Helen Egger, a psychiatrist specializing in early childhood who has done research seeking to distinguish typical childhood tantrums from those that may be a sign that something is wrong.

Tantrums remain very common in 3-year-olds, and then they become less frequent over the next couple of years, said Dr. Egger, the chairwoman of the department of child and adolescent psychiatry at NYU Langone Health. Developmentally, they come right when fear and aggression peak, but the child is still working on language skills.

So what should parents do, faced with a tantrum?

“I don’t think any child having a tantrum can respond to what I hear all the time: ‘Use your words,’” Dr. Egger said.

Instead, the parent should try to be a “container,” she said, to keep the child safe, and then talk about it afterward. “You have to see it like a storm,” she said. “Manage the storm, then find out what was happening beforehand.”

“Things are unglued,” Dr. Egger said. “What do children need to become reglued? They need that feeling that there’s a competent grown-up who is there to contain them.” The last thing you want, she said, is for a child to have the feeling of pushing against a wall, only to see that wall fall down.

Dr. Potegal suggested that parents think about what function a tantrum is serving for a child: Is it attention getting, with negative attention better than no attention? Is there something tangible at stake, like food or a toy? Or is there something the child wants to escape doing?

Tantrums typically happen when children are hungry or tired or when there has been some significant change in their routine, Dr. Egger said. The children with more problematic tantrums, she said, are the ones who are triggered by anger and frustration, or by transitions — they aren’t particularly tired, they’re just furious that it’s bedtime or bath time.

And sometimes there’s no clear trigger, which can be a sign that all is not well. “Parents describe the tantrums just coming out of the blue,” Dr. Egger said, “‘Do you want to wear your blue shoes or your red shoes?’ and you’re done.”

It’s less common and more concerning for children to have tantrums regularly with babysitters or teachers, and in fact, Dr. Egger said, “kids who have tantrums outside of the home at school and day care, at church, outside, that’s another flag.”

Children with increased frequency of tantrums — almost every day, or even more often — and who bite, kick, hit or break things during the tantrums are the children to worry about, Dr. Egger said. Such children are eight times more likely to meet criteria for “impairing mental health disorders,” such as anxiety disorders, attention deficit hyperactivity disorder and depression, and also more likely to develop problems later on. “And when we follow these children into early and middle childhood, these aggressive early childhood tantrums may be associated with emotional disorders like anxiety and depression,” she said.

“Most children who have tantrums that are really severe in duration and intensity aren’t just normally angry, they have something else wrong with them,” said Dr. Gabrielle Carlson, professor of psychiatry and pediatrics at Stony Brook University School of Medicine. “They may have A.D.H.D. or depression or another psychiatric disorder.” For a long time, she said, tantrums were understood as aggression, but more recently, psychiatrists have begun to think of these children with “a very short fuse and a very large explosion” as being highly irritable, rather than aggressive.

A child’s irritability may be a clue to some medical problem causing pain or distress; it’s a rare explanation for tantrums, but there are certainly children whose tantrums decrease or stop when they get treated for reflux, or some other cause of underlying discomfort, or for something that is impairing their ability to communicate and leaving them frustrated. And children with developmental disabilities and autism also often have tantrums, so it’s important to assess the child’s general development.

“My son, who has grown up to be quite a nice lad, used to have really, really bad temper tantrums,” Dr. Carlson said. “He would scream and yell and throw his shoes. It would last about 45 minutes.” She would put him in his room, “and then he would come out, he would tell me he was mad and sad.” She worried about it, she said, and she thought it was abnormal. “He turned out to have A.D.H.D., it wasn’t just a normal kid being a little bit delayed outgrowing the terrible 2s,” she said. “He had a developmental condition, and the oppositionality and poor anger management were among the signs.”

So if tantrums are frequent or aggressive (hitting, kicking, biting, breaking things), parents should by all means get help, rather than blaming themselves. If you find yourself changing family routines or avoiding triggers out of terror that you’ll provoke a tantrum, that’s another sign that you should seek help. And finally, if an experienced day care provider or preschool teacher says these tantrums are something out of the ordinary, take that seriously, though a healthy typical child can certainly have an occasional nuclear meltdown, and many of us have terrible memories of one public agony or another.

But if it’s happening regularly, talk to your pediatrician, think about possible medical problems, and get a referral to someone experienced in early childhood who can evaluate the child for mental health issues — a child psychiatrist or psychologist or developmental specialist. To say that extreme tantrums may be a sign of something else is only to say that that child — and those parents — may need some extra help, and the sooner the better.

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