Excessive tantrums in preschoolers may indicate serious mental health problems

Certain types of tantrums in preschoolers may be a sign of serious emotional or behavioral problems, according to researchers at Washington University School of Medicine in St. Louis. Although temper tantrums are common and normal in young children, the researchers found that long, frequent, violent and/or self-destructive tantrums may indicate the presence of psychiatric illness.

While temper tantrums are common and normal for young children, Washington University researchers have identified several risk factors associated with tantrums that may indicate the presence of psychiatric illness.

The research team reports its findings in the January print issue of The Journal of Pediatrics currently available online. Researchers compared tantrums in healthy children to the tantrums in children diagnosed with depression or disruptive disorders, such as attention-deficit/hyperactivity disorder. Most children have temper tantrums at some point, but the researchers found healthy children tend to be less aggressive and generally have shorter tantrums than their peers with depression and disruptive disorders.

“It’s clearly normal for young children to have occasional tantrums,” says first author Andrew C. Belden, Ph.D., a National Institute of Mental Health (NIMH) post-doctoral research scholar in child psychiatry. “Healthy children may even display extreme behaviors if they’re very tired or sick or hungry. But if a child is regularly engaging in specific types of tantrum behaviors, there may be a problem.”

The researchers studied 270 children between 3 and 6 years old. They gathered the information about tantrums from a parent. The children were divided into four groups according to psychiatric symptoms: no psychiatric diagnosis, major depressive disorder, disruptive disorder, or depression and disruptive disorder. All of the children were part of a larger NIMH-funded study of psychiatric illness in preschoolers.

“We’ve been following these children for several years,” says principal investigator Joan L. Luby, M.D., associate professor of child psychiatry and director of the Early Emotional Development Program at the School of Medicine. “It’s important to find age-specific ways to diagnose depression and other problems in young children because it can be difficult to get very young children to tell you about their feelings. We’ve successfully used narrative and observational techniques, but characteristics of tantrums when present might be another helpful tool.”

Luby, Belden and colleagues identified five types of tantrum behavior that appeared to be connected with depression or diagnosable disruptive disorders.

The first involves extremely aggressive behavior during a tantrum. When a toddler displays aggression directed at a caregiver or violently destructive behavior toward an object such as a toy during most tantrums, parents should be concerned. The study found that these children tend to have diagnoses of ADHD, oppositional-defiant disorder and other disruptive disorders.

The second worrisome tantrum behavior is when toddlers intentionally injure themselves — actions such as scratching until the skin bleeds, head-banging or biting themselves.

“It doesn’t matter how long these types of tantrums last or how often they occur, self-injurious behavior almost always was associated with a psychiatric diagnosis in this study,” Belden says. “Children with major depressive disorder tended to hurt themselves. We didn’t see that in healthy kids or those with ADHD and other disruptive disorders. It really surprised us that this type of behavior was emerging at such a young age.”

Other “red flags” involved children who had more than five tantrums a day for several consecutive days. Very long tantrums also signaled a problem. Healthy children might have a tantrum that lasts 10 or 11 minutes, but several children in the study, especially those with disruptive disorders, averaged more than 25 minutes per tantrum.

Finally, when preschoolers are unable to calm themselves following a tantrum, they appear to be at much greater risk of psychiatric problems.

“If a child is having tantrums and parents always have to bribe the child with cookies or other rewards to calm him or her down, this may be something more serious than normal toddler volatility,” Belden says.

It’s important, he stresses, to replicate these findings in studies of other children and to more rigorously classify what types of behavior may be problematic. Since this study relied on parent reports of children’s tantrum behaviors, future studies will involve video analysis of them.

Belden, who has two young children, became interested in tantrum behavior because of the very different tantrum styles displayed by each of his two children. His advice for parents is not to worry when a child has a tantrum but to pay attention to how the child is behaving during the tantrum.

“The best news from this paper is that it’s normal for children to display excessive behavior sometimes,” Belden says. “If a child lashes out at you, it doesn’t mean, ‘Oh my gosh! They’re doomed!’ But if they lash out and hit you every time, there might be a problem. And if they hurt themselves intentionally, I think it’s best to consult a pediatrician or mental health professional.”

Belden, AC, Thomson NR, Luby JL. Temper tantrums in healthy versus depressed and disruptive preschoolers: defining tantrum behaviors associated with clinical problems. The Journal of Pediatrics, vol. 151:6, Jan. 2008. doi:10.1016/j.jpeds.2007.06.030

This research was supported by a grant from the National Institute of Mental Health.

Washington University School of Medicine’s full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.