Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Dr. Barbara J. Howard
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.