1. Tantrums Telana Fairchild
Telana Fairchild
How many of you have experienced frustration or anger? How many of you have wanted to scream when you’ve experience frustration or anger? Exactly, but most of us probably didn’t behave this way. My point is this is the same emotions children experience unlike us they don’t know what else to do other than scream or yell.

2. Objectives Definition Characteristics Triggers/ Causes
Anticipatory Guidance
Normal vs. Abnormal
Parents
NPs
Let’s discuss tantrums and how we as NP’s can be helpful.

3. Definition
Temper tantrum: a child’s way of showing frustration or anger by whining and crying to screaming, kicking, hitting, and breath holding.
Begins to occur when child wants autonomy
Have a hard time expressing what they want
Looking for limits
Generally, children begin to develop and understand more than what they can express and when they are unable to express their wants and desires frustration occurs; or when they are attempting to be independent they may find task like eating, getting undressed/dressed a challenge. Typically, the older child, two year olds, will try to push limits and look for boundaries.

4. Characteristics Normal part of development
Equally common in boys and girls
Usually occur between the ages of 15 months to 3 years
Should taper off after 3yrs
Based on kids' temperaments
Lack inhibitions or control
Tantrums are normal part of development occurring equally among girls and boys. Tantrums don't have to be seen as something negative. These behaviors can start as early as 15mo and continue until 3yrs; however, it should taper off. 3-4yrs now kids have the communication skills they need to ask for what they want and they are beginning to understand limits. As noted by Daniels article, 20% of 2yr olds, 18% of 3yrs olds, and only 10% of 4 yrs olds have at least one tantrum every day (2012). Tantrums are based on kid’s temperaments: which can vary dramatically — so some kids may experience regular tantrums, whereas others rarely have them. Also, a different temperament means different triggers. Also, unlike adults, kids don't have the same inhibitions or control, nor have they have learned to cope with emotions.

5. Triggers/Causes Be Aware of Temperament Family-Child Interaction
Environmental Influences
Hunger
Sleep
Attention
R/o Developmental or Health Status
Let’s review some triggers and causes of tantrums beginning with temperament:
what are child's triggers for high intensity, negative mood, reactivity to sensory, high persistence?
Family-child interactions: what is child trying to communicate with tantrum, specific interactions that trigger tantrum, how do parents respond does it calm child or escalate child, do parents offer support without giving in to unreasonable demands
Environment: is tantrum linked to changes in care setting or provider, do others in family express stress negatively, does family stress initiate tantrum.
Dev/HS: can child express frustration through speech, delays in routines that cause frustration, chronic conditions causing pain (eczema, rhinitis), is sleep a problem
These are areas we would investigate to discover why tantrums are an issue or use these as areas for guidance. But we can’t forget that the most common triggers are hunger, sleep and lack of attention.
Exs. Of temperaments: Richard Harris, PhD- Hyperactive temperament predisposes the child to respond with fine- or gross-motor activity. Distractible temperament predisposes the child to pay more attention to his or her surroundings than to the caregiver. High intensity level temperament moves the child to yell, scream, or hit hard when feeling threatened. Irregular temperament moves the child to escape the source of stress by needing to eat, drink, sleep, or use the bathroom at irregular times when he or she does not really have the need. Negative persistent temperament is seen when the child seems stuck in his or her whining and complaining. Low sensory threshold temperament is evident when the child complains about tight clothes and people staring and refuses to be touched by others. Initial withdrawal temperament is found when children get clingy, shy, and unresponsive in new situations and around unfamiliar people. Poor adaptability temperament shows itself when children resist, shut down, and become passive-aggressive when asked to change activities. Negative mood temperament is found when children appear lethargic, sad, and lack the energy to perform a task.

6. Anticipatory Guidance
Distraction
Give choices
Give control
Praise good behavior and accomplishments
Consistency and Routines
Discipline by teaching and
protecting
Our text, “Bright Futures”, recommends the 15 and 18 month visit we discuss temper tantrums with parents and give guidance or as needed. Parents need to understand tantrums are an opportunity for teaching and being aware of child’s temperament and triggers will help. Teach parents not to meet child’s anger but to stay calm, encourage separating themselves at times and finding humor in these challenging times with other adults. Tell parents to allow the child time to also calm down, don’t talk until they’ve gained control, if in public place remove them to home or car. Don’t allow biting, hitting or kicking behaviors. Don’t give into behaviors or request to stop tantrum. Also after the tantrum, encourage parents to hug children, explain they love them no matter what and give clear explanation of what is expected and why the behavior is bad. Some key tips include the use of
Distraction: Instead of continually saying “No”, remove or avoid things that will cause bad behavior or if something is frustrating to child remove or stop activity change to something else. (example if throwing sand in sand box, remove child and start a new activity Explain why they are removed and can’t play with sand, very simply. ),
Choices: Allow choices that are within the desired outcome, example would you like to put on your pants or shirt first or would you like to brush your teeth or change into your pajamas first before bed, don’t give choices that will allow child to say no to desired outcome ex. Would you like to brush your teeth? Giving choices allows control but other control options are
Control: allow the child to turn pages of book while reading or use a spoon while eating. Caution, to not give tasks that maybe out of developmental range this could lead to frustration.
Praise good behavior and accomplishments: be sure to catch them behaving or doing something correctly, especially when they are in a situation that might normal cause a tantrum. Parents should say more than good job, they should explain what behavior they are pleased with and why.
Consistency and routines: try to have daily routines and consistencies for child, if there is a change prepares the child, explain simply the change and the expected behavior. In the routines allow them time to express their energy (playing, running, etc).
Discipline: Again parents need to stay in control, if needed take a moment to calm down. Can try stepping to next room and using the counting technique and try to figure out why the child is showing frustration. Be consistent, avoid spanking, explain in short simple terms what they did wrong. Explain to other care providers the expectations and limits and the disciplinary responses so consistency is achieved. Teach child harm to self or others is inappropriate. When necessary may need to gentle restrain child if harmful or dangerous and use of time-out is helpful, gives them time to collect themselves and calm down (time-out: mins/age).
Tell parents tantrums will happen they are normal developmental milestone. When tantrums do happen they should ignore behavior to get attention, however, if threats of danger try to hold child and explain you will allow them to be free once they’ve calmed down or put them in a quiet area their crib or time-out. Once they’ve gained control discusses the appropriate behavior and why they got frustrated and move on to another activity. NEVER given in to tantrum, will only increase the frequency.
At age two: start helping them express their emotions
Continue these throughout childhood. However, note that after the age of three these behaviors may still exist because they’ve learned tantrums get them what they want, may need additional help in these situations.
Let’s review what is normal or abnormal so we can give the best advice to parents.

7. Normal vs. Abnormal Age 12mo-4yrs
Crying, flailing arms or legs, falling to the floor, pushing, pulling, or biting
Up to 15min
Less than five times a day
Return to normal mood b/w tantrums
Beyond age 4yrs
Injury to themselves or others
Longer than 15min
More than five times day
Persistent negative moods b/w tantrums
Sleep disorders, enuresis, aggressive behavior, or extreme anxiety
As you can see research has been able to define certain characteristics that are considered normal and abnormal for tantrums. Keep in mind this is a normal developmental process for children 12mo to 4yrs, but much after this we including parents should be concerned. Also, it should be noted just one characteristic of abnormal behavior should be consider reason for further evaluation, so if a 18mo old is having a tantrum more than 15 minutes or more than five times a day we with the parent should evaluate why these types of behaviors are occurring. As one article noted, the frequency and quality of tantrum behavior are key aspects when deciding if tantrum is abnormal. Of note also, is socioeconomic status doesn’t seem to have any relationship with behaviors of tantrums. In another study, they concluded there is no definitive indication of behaviors during a tantrum that quantifies it to be at risk or risk for psychiatric disorders; although, they did find five styles of behaviors that indicated differences between a healthy group of kids from those of disruptive or depressive diagnoses. The five styles are very similar to same findings in the table shown here. Therefore, we as clinicians need to be very detailed in questions and assistive to the parents and recognize when there may be a clinical reason for tantrums or guidance to have better control and correct the behavior. If the diagnoses of disruptive or depressive behavior is found, we should act and work towards a treatment goal.
(if time allows sum up)…… (click to next slide) When tantrums become abnormal, parents need to consult PCP and referrals maybe necessary.
The five tantrum styles are as follows: First, preschoolers’ consistent (i.e., more than 50% the time during the last 10–20 tantrum episodes) display of aggression directed at caregivers and/or violently destructive behavior toward objects may indicate clinical problem. Second, when preschoolers intentionally engage in self-injurious behavior during tantrums, regardless of tantrum frequency, duration, intensity, or context, this behavior should be considered very serious. Self-injurious behaviors during tantrums were rarely reported among preschoolers with the exception of those in the MDD groups. Third, preschoolers who display 10–20 discrete tantrum episodes on separate days at home, during a 30-day period, or on average who have more than 5 tantrums a day on multiple days while at school or outside of home/school are at greater risk of having a serious clinical problem. Fourth, extended tantrum duration, lasting longer than 25 minutes on average, may indicate problems that are more serious. Lastly, preschoolers who are typically unable to calm themselves (i.e., frequently require external assistance from a caregiver), regardless of tantrum intensity, frequency, or context, are at a much greater risk of having a clinical problem. Based on the current findings, we propose that preschoolers who consistently exhibit the behaviors outlined may be in need of a referral to a mental health clinician for further evaluation. However, it is important to note that certain tantrum behaviors, such as a sudden onset of tantrums because of hunger, sleep problems, or illness should not be considered alarming.

8. When parents need to call us
If tantrums are increasing in: frequency, intensity, or duration
If self-injurious, hurtful to others, depressed, signs of low self-esteem, or overly dependent
If have questions, uncomfortable, or keep giving in
Parents are instructed by websites, resources, and us to call if they note any of these abnormal characteristics of a tantrum. We should know how to teach and guide parents during these difficult times and be helpful if there is any underlying physiological causes and help treat and be a resource.

9. Guidance for the NP’s 5-20% of children have severe temper tantrums
Questions we should ask (History)
Remember the abnormal characteristics
R/O physiological causes (PE)
Prevention best method
Referrals or treatment of illness
We need to be aware there are causes of severe tantrums and need to be prepared to be helpful to these children and parents. Try to illicit the subjective details of the tantrum by asking questions like…..If they accompany sleep disorders, aggression, or enuresis they may signal an underlying emotional problem. When does the child have a tantrum? How long does it last? How often does the child have tantrums? What circumstances provoke the tantrums? What does the child do during the tantrum? What is the child’s behavior like between tantrums? Have there been any changes in the child’s home or school situation such as a new sibling, a recent move, or parental conflicts? How does the parent react to the tantrum? How have the parents handled the tantrums? Is the child having any other behavioral problems accompanying the tantrums? Keep in mind the abnormal characteristics discussed previously and keep in mind any signs that may point to the cause of the tantrum being related to chronic illness (Eczema or Rhinitis), conditions (Asperger’s syndrome or Autism), delays or developmental issues, or hearing or vision problems. After the detailed history, obtain some objective data by examining vision, hearing, and developmental milestones. Although there isn’t one specific diagnostic tool, there are vision test, hearing test, and developmental test that can be done. Instruct parent about ways to prevent the tantrums, be specific to problems that arose during the history. Prevention is best method for treatment however, if physiologic reason arise from the subjective and objective data they should be treated either by referring to specialist or pharmacological means, if needed.

10. What questions do you have?
So, who’s ready to throw a temper tantrum? Or I mean, be helpful when it comes to temper tantrums.

11. References
American Academy of Pediatrics. (2011). Temper Tantrums: A Normal Part of Growing Up. Retrieved from mily-life/family- dynamics/communication- discipline/Pages/Temper- Tantrums.aspx
Belden, A.C., Thomson, N.R., & Luby, J.L. (2008). Temper tantrums in healthy versus depressed and disruptive preschoolers: Defining tantrum behaviors associated with clinical problems. Journal of Pediatrics, 152 (1),
Daniels, E., Mandleco, B., & Luthy, K.E. (2012). Assessment, management, and prevention of childhood temper tantrums. Journal of American Academy of Nurse Practitioners, 24, 569–573. doi: /j x
Hagan, J.F., Shaw, J.S., & Duncan, P.M. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.

12. References
Harrington, R.G. (2004). Temper Tantrums: Guidelines for Parents. National Association of School Psychologists. Retrieved from
Pendley, J.S. (2012). Temper Tantrums. The Nemours Foundation: KidsHealth. Retrieved from at_i d=146&article_set=21609
Wakschlag, L.S., Choi, S.W., Carter, A.S., Hullsiek, H., Burns, J. McCarthy, K.,…Briggs-Gowan, M.J. (2012). Defining the developmental parameters of temper loss in early childhood: Implications for developmental psychopathology. Journal of Child Psychology and Psychiatry, 53 (11), doi: /j x.