CHAPTER 51

Temper Tantrums

Geeta Grover, MD, FAAP, and Peter Jinwu Chung, MD, FAAP

Temper tantrums are common, normal, age-related behaviors in young children. To a certain extent, oppositional behaviors such as negativism, defiance, and tantrums are part of the normal progression toward self-reliance and independence. Toddlers need to assert their freedom and explore their environment, which often puts them at odds with the limitations imposed by society and well-meaning parents. Young children cannot appreciate that rules and limitations have been established in the interest of their own safety and well-being. They see only that their own desires have been thwarted, and they may react to this disappointment with intense emotions. Children are not simply upset because they cannot have their way. They are angry and frustrated, and they lose control over their emotions. During tantrums, children cry and scream uncontrollably. They may fall to the floor, bang their heads, kick their feet, pound their hands, and thrash about wildly. Some children may throw things, try to hit one another, or destroy property.

Such intense displays of anger may be a terrifying experience for children and parents. Some children use tantrums to gain attention, whereas others use them to achieve something or avoid doing something. Recurrent temper tantrums may strain relationships among parents, children, and other family members.

Epidemiology

Temper tantrums are noted most often in children who are 2 to 3 years of age, but they may occur any time between the ages of 1 and 5 years. Parental surveys reveal that approximately 20% of 2-year-olds, 18% of 3-year-olds, and 10% of 4-year-olds have at least 1 tantrum per day. Most children can express their feelings verbally by 3 to 4 years of age, at which point temper tantrums begin to taper off. Children who cannot express their feelings well with words, such as children with developmental delays, especially those with speech and language delays or with an autism spectrum disorder (ASD), are more likely to continue to have tantrums. Boys and girls are affected equally. Although temper tantrums are unusual in school-age children, they often reappear in the form of verbal tantrums during adolescence, when autonomy and independence once again become developmental issues.

Pathophysiology

Temperament, or adaptability and emotional style, affects the ease with which children adjust to environmental inputs and their reactions to these inputs. Temperament is the “how” of behavior, as opposed to the “why.” It is innate rather than learned. Although inherent from birth, temperament may be modified in the early years by children’s experiences and interactions. Stella Chess, MD, and Alexander Thomas, MD, identified 9 major temperamental traits based on their study of children’s behavioral characteristics during the 1950s: activity level, rhythmicity (regularity), approach or withdrawal, adaptability, intensity, mood, persistence and attention span, distractibility, and sensory threshold. Three common patterns of temperament based on whether a child shows a greater or lesser degree of each of these traits are easy (high rhythmicity and adaptability with a positive mood), slow to warm up or shy (slow adaptability and tendency to withdraw initially in new situations), and difficult or challenging (low rhythmicity and adaptability, resulting in negative and intense reactions to the environment).

Appreciation of children’s temperament allows parents to anticipate and understand their children’s reactions, thereby affording them the opportunity to rethink how the parents interpret and respond to their children’s behaviors. Ultimately, this knowledge allows parents to guide children in ways that respect their individual differences. Temperament does not excuse children’s unacceptable behaviors, but it does provide some insight into the origins of problematic behaviors, such as tantrums. For example, allowing extra time in the morning for the high–activity-level child with high distractibility and low attention span to get ready for school may avoid the daily negative interactions between parent and child. A discussion of temperament is not complete without noting that ultimately it is the “goodness of fit” between parental and child temperaments that is the key issue. What may appear to be a behavioral problem may in fact be a mismatch between parental and child temperaments (eg, a high-energy and high-intensity child may be quite challenging for the slow to warm up or shy parent). It is important to help parents appreciate that such mismatches in temperamental traits between themselves and their children do not necessarily represent problems in their children’s character.

Understanding the child’s level of maturity and the developmental tasks normally associated with the toddler and preschool years, which is when temper tantrums most often occur, facilitates further understanding of tantrum behavior. Young children who are exploring the world and developing a sense of autonomy think primarily in egocentric terms. They view reality from their own perspective and are unable to appreciate the perspective of other individuals. Only as they mature and enter school do they learn to recognize the position of others and begin to develop a sense of morality—of right and wrong. Toddlers may become frustrated or angry because of their lack of control over the world, their inability to communicate, or limitations of their cognitive and motor abilities, which do not allow them to accomplish desired tasks. Unlike adults, who can verbalize frustrations or simply walk away from unpleasant situations, young children have neither the sophisticated ability to articulate their feelings nor the freedom to walk away. Therefore, they may react to disappointments with temper tantrums. With cognitive and emotional maturation, children should gradually learn to exhibit more emotional control and/or use language to express themselves. If caregivers consistently reinforce tantrum behavior, however, such as by “giving in,” this maturation process may be delayed.

Temper tantrums may be classified as normal or problematic based on their cause, frequency, and characteristics. Normal tantrums can simply be demands for attention or signs of frustration, anger, or protest. In the interval between tantrums, the child’s disposition and mood are normal. The well-behaved 3-year-old boy who has an occasional tantrum after the birth of a sibling, the girl age 2 years 6 months who throws a tantrum to express frustration because no one understands what she is trying to say, and the 2-year-old boy who cries uncontrollably because he cannot complete the puzzle he started or run fast enough to keep up with his 4-year-old brother are all examples of normal tantrums. A typical reason for an avoidance-type tantrum is not wanting to go to bed at bedtime. All types of tantrum are more common when children are tired, ill, or hungry, because their ability to cope with disappointment and frustration is limited under these circumstances.

Frequent tantrums (>5 per day) and tantrums that result in destruction of property or physical harm to the child or others are signs of problematic tantrums (Box 51.1). These tantrums may result from factors that are beyond the child’s control, such as parental problems, school difficulties, or health-related conditions (Box 51.2). For example, the child with unrecognized hearing loss may be performing poorly at school and resort to tantrum behavior in frustration. Marital discord or domestic violence may create anxiety for a child, which may manifest as frequent or destructive tantrums. Additionally, problematic temper tantrums may be a symptom of an underlying psychiatric or neurodevelopmental condition.

Differential Diagnosis

Temper tantrums are readily recognizable because of their classic pattern in which a child becomes frustrated, reacts physically, and cries or screams.

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