When to worry about kids' temper tantrums

New Northwestern Medicine research will give parents and professionals a new tool to know when to worry about young children's misbehavior. Researchers have developed an easy-to-administer questionnaire specifically designed to distinguish the typical misbehavior of early childhood from more concerning misbehavior. This will enable early identification and treatment of emerging mental health problems, key to preventing young children struggling with their behavior from spiraling downward into chronic mental health problems. The new tool also will prevent rampant mislabeling and overtreatment of typical misbehavior.

Surprise Finding: Temper Tantrums Not Frequent

In a surprising key finding, the study also debunks the common belief temper tantrums are rampant among young children. Although temper tantrums among preschoolers are common, they are not particularly frequent, the research shows. Less than 10 percent of young children have a daily tantrum. That pattern is similar for girls and boys, poor and non-poor children and Hispanic, white and African-American children.

"That's an 'aha!' moment, "said Lauren Wakschlag, professor and vice chair in the department of medical social sciences at Northwestern University Feinberg School of Medicine and lead author of a paper, published August 29 in The Journal of Child Psychology and Psychiatry. "It gives a measurable indicator to tell us when tantrums are frequent enough that a child may be struggling. Perhaps for the first time, we have a tangible way to help parents, doctors and teachers know when the frequency and type of tantrums may be an indication of a deeper problem."

Until recently, the only diagnostic tools available for preschool behavior problems were those geared to older children and teens with more severe, aggressive behavior. More recently, there has been emphasis on measures developed specifically for preschool children.

For the study, funded by the National Institute of Mental Health, researchers developed the new questionnaire, the Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB), to ask parents of almost 1,500 diverse preschoolers, age three to five, to answer questions about their child's behavior. The questionnaire asked about the frequency, quality and severity of many temper tantrum behaviors and anger management skills over the past month.

The results allowed researchers to rate children along a continuum of behavior from typical to atypical, rather than focusing only on extreme behavior. Having a continuum will allow mental health professionals to intervene before there is a serious problem or watch and wait if a child is in the middle range. Early childhood is a critical period to identify a problem, because once negative problems become entrenched, they are harder to treat. This continuum also provides a barometer for determining when a child is improving on his/her own or through treatment.

"We have defined the small facets of temper tantrums as they are expressed in early childhood. This is key to our ability to tell the difference between a typical temper tantrum and one that is problematic," Wakschlag said.

For example, the study found that a typical tantrum may occur when a child is tired or frustrated or during daily routines such as at bedtime, mealtime or getting dressed. An atypical tantrum may be one that occurs "out of the blue" or is so intense that a child becomes exhausted. While any of these behaviors may occur in some children from time to time, when these atypical forms of tantrums occur regularly, they become a red flag for concern.

This developmentally-based approach is in stark contrast to the commonly used Diagnostic and Statistical Manual of Mental Disorders (DSM), which does not provide age-specific markers for determining clinical significance.

For example, a symptom of behavior problems in DSM is defined as "often loses temper."

"The definition of 'often' may vary substantially for younger and older children and depend on family stress levels and other mitigating factors," Wakschlag said. "Since most preschool children tantrum, this vague criteria makes it exceptionally difficult for providers to determine when behavior is of clinical significance in early childhood."

"There's been a real danger of preschool children with normal misbehavior being mislabeled and over-treated with medication," Wakschlag said. "On the other hand, pediatricians are hampered by the lack of standardized methods for determining when misbehavior reflects deeper problems and so may miss behaviors that are concerning. This is why it's so crucial to have tools that precisely identify when worry is warranted in this age group."

Linking Tantrums to Mental Health Problems, Social Functioning and Brain Reactivity in Early Childhood

To establish the clinical significance of these findings, Wakschlag, colleague Margaret Briggs-Gowan, from the University of Connecticut Health Center, and their collaborators are now examining how these tantrum patterns are linked to a range of mental health problems and problems in daily functioning such as getting along in school, with siblings and general social skills. In collaboration with Northwestern neuroscientist, Joel Voss, the study also is beginning to use brain-imaging techniques to uncover links between particular patterns of brain reactivity and these early problem behaviors.

Replicating Findings in Larger Sample

In addition, Wakschlag and colleagues are replicating their findings about the developmental pattern of misbehaviors in a second sample of 2,200 children, with the next step being disseminating the tool. The questionnaire is now 118 questions but researchers hope to use state-of-the-art measurement science to crunch it down to about 25 key questions. An ultimate goal of the research team is to widely disseminate the MAP-DB questionnaire in a brief computerized form for parents to fill out in pediatric waiting rooms, with the computer generating immediate feedback to pediatricians prior to the appointment.