January 2, 2008— Consistently displaying aggressive or violent behavior during childhood tantrums, having long-lasting tantrums, engaging in self-injury during tantrums, and having difficulty recovering from such outbursts, are all possible red flags of a psychiatric disorder, a new study suggests.

The research, published in the January issue of the Journal of Pediatrics, found that disruptive preschoolers aged approximately 3 to 6 years were more violent during tantrums and had significantly more tantrums at school and daycare than healthy preschoolers and preschoolers who are depressed. These disruptive youngsters also had more difficulty recovering from tantrums than their healthy counterparts.

Carried out by researchers at the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, and the Missouri Institute of Mental Health, University of Missouri, the study also found that depressed preschoolers were more aggressive than healthy children and displayed significantly more self-harmful tantrum behaviors than healthy and disruptive children.

"Healthy children were reported to show significantly fewer violent, self injurious, destructive and orally aggressive tantrum behaviors than children with mood disorders, disruptive disorders or both," commented Andy C. Belden, PhD, and colleagues. "Furthermore, healthy pre-schoolers had less severe and shorter tantrums and required less recovery time compared with children with DSM-IV [ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] diagnoses."

Preliminary Tantrum Behavior Guidelines

These results provide preliminary guidelines to parents, teachers, and practitioners in identifying tantrum behaviors that may be markers of a psychiatric disorder and require mental health referral, the authors wrote.

The study sample included youngsters aged 3 to 5.11 years from the greater St. Louis area who were recruited through pediatricians' offices, primary care practices, preschools, and daycare centers. Using the Preschool Feelings Checklist that screens for early onset disorders, researchers selected a sample of 279 subjects that included 150 healthy children; 21 who had symptoms of depression but no disruptive disorder; 54 who had attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder (pure disruptive); and 54 with both depression and a disruptive disorder.

The group with both depression and a disruptive disorder was significantly older than the healthy and pure disruptive groups and came from households with significantly lower incomes.

Classifications of Tantrums

During a 3- to 4-hour assessment, trained personnel interviewed primary caregivers about their children's behaviors, emotions, and age-adjusted manifestations of psychiatric symptoms. They used the temper tantrum section of the Preschool Age Psychiatric Assessment (PAPA) to determine the intensity and frequency of tantrums. The children were assigned to 1 of 3 possible tantrum intensity classifications: normative (rarely includes excessive crying, shouting, and no destruction, violence, or both), excessive tantrums without aggression or violence (but includes shouting, crying, or nondirected flailing movements), or excessive tantrums with aggression.

The study found that the comorbid group was 9 times more likely than the healthy and pure depressed groups to have displayed tantrums with violent aggression, destructive aggression, or both. Children in the pure disruptive group were 5 times more likely vs those in the healthy and depressed groups to have displayed tantrums with violent or destructive aggression.

Young Kids With Depression More Likely to Self-Injure During Tantrums

The depressed preschoolers, regardless of whether they also had a disruptive disorder, were significantly more likely to have engaged in self-injurious tantrum behaviors vs kids in all other groups. "Although such behaviors are well known in older samples, this finding was particularly notable in young children," the authors wrote.

Looking at common sites for tantrums, the study found that the comorbid group displayed significantly more tantrums within the home vs the other groups. At school, the comorbid and pure disruptive groups had higher tantrum frequency scores than the healthy group.

As for tantrum recovery, the investigators found that kids in the comorbid group were 6 times more likely to be reported by caregivers as having difficulty recovering from tantrums vs children in the healthy group.

High-Risk Tantrum Styles

These results suggest that there are 5 high-risk "tantrum styles":

• Consistently (> 50% of the time during the last 10 - 20 tantrums) displaying aggression directed at caregivers, violently destructive behavior toward objects, or both;
  
  
• Intentionally engaging in self-injurious behavior during tantrums regardless of tantrum frequency, duration, intensity, or context;
  
  
• Displaying 10 to 20 discrete tantrum episodes on separate days at home during a 30-day period or, on average, having more than 5 tantrums a day on multiple days;
  
  
• Having tantrums lasting more than 25 minutes on average; and
  
  
• Being unable to calm oneself regardless of tantrum intensity, frequency, or context.

"On the basis of these findings we propose that preschoolers who consistently exhibit the behaviors outlined may be in need of a referral to a mental health clinical for further evaluation," the authors wrote. They noted, though, that sudden onset of tantrums because of hunger, sleep problems, or illness should not be alarming.

The next step for researchers, said the authors, is to develop an operational definition of a "normal temper tantrum."

The National Institute of Mental Health supported this study.

J Pediatr. 2008;152:117-122.

Clinical Context

Study Highlights

• Included were preschoolers aged 3 to 5.11 years recruited by random geographic area sampling from 1 city, through pediatricians' offices and preschool or daycare centers.
• The Preschool Feelings Checklist, a validated tool for identifying children at risk for or with mood disorders, disruptive disorders, or both, was used to screen children.
• 279 children were identified and categorized with use of DSM-IV criteria into 1 of 4 diagnostic groups: healthy (n = 150), pure depressed (n = 21), pure disruptive (n = 54), and comorbid depressed/disruptive (n = 54).
• Dyads participated in 3- to 4-hour laboratory assessment during which caregivers (94% mothers) were interviewed about their children's behaviors, emotions, and manifestations of psychiatric symptoms with use of the PAPA.
• Trained interviewers administered the PAPA, and the interviews were audiotaped for quality control.
• The temper tantrum section of the PAPA was used to assess the intensity, duration, and recovery of tantrums.
• Preschoolers were assigned to 1 of 3 possible tantrum intensity classifications: normative tantrums, excessive without aggression, and excessive with aggression (including episodes of violence toward objects, people, or both).
• 50% of preschoolers were boys, 30% were 3 years old, 50% were 4 years old, two thirds were white, 30% were black, and 58% of parents had a college degree.
• Overall, there was a significant association between tantrum intensity and diagnostic group.
• The comorbid group was more likely to engage in excessive tantrums with aggression vs the pure depressed (odds ratio [OR], 9.77; P < .001) and healthy groups (OR, 9.21; P < .001).
• The pure disruptive group was more likely to engage in temper tantrums with aggression than the pure depressed (OR, 5.78; P < .01) and healthy (OR, 5.14; P < .001) groups.
• There were differences between preschoolers who engaged in nonaggressive tantrums and those who engaged in excessive tantrums with aggression.
• The comorbid group was 9 times more likely than the healthy and pure depressed groups to display tantrums with violent aggression, destructive aggression, or both.
• The pure disruptive group was 5 times more likely than the pure depressed or healthy groups to display tantrums with violent or destructive aggression.
• There was no effect of age or sex on tantrum factors.
• The comorbid group had significantly longer duration of tantrums and were 6 times more likely to be reported by caregivers as having delayed recovery from tantrums.
• The pure disruptive group displayed more tantrums at home and outside the home or school as did the comorbid group vs healthy group.
• Overall, disruptive preschoolers displayed violence more frequently, had more tantrums at home and at daycare, and had a more difficult time recovering from the tantrums.
• Depressed preschoolers were more aggressive toward objects and other people and displayed more self-harmful tantrum behaviors.
• The authors suggested that despite the findings, the results did not indicate whether tantrums were predictive of psychiatric disorders.
• They offered 5 tantrum styles that could be associated with higher risk: aggression directed at caregivers, objects, or both; self-injurious behaviors; frequent tantrums (more than 10 - 20 on separate days at home during a 30-day period); extended duration of more than 25 minutes, and inability to calm themselves.
• Sudden onset of tantrums was not considered alarming in the setting of hunger or sleep problems.

Pearls for Practice

• Patterns of temper tantrums of preschool children differ according to diagnostic categories of healthy, pure depressed, pure disruptive, and comorbid depressed/disruptive.
• Preschoolers with depressive features are more likely to display self-harm and aggression toward caregivers and objects, whereas those with disruptive features are more likely to display behaviors associated with greater violence and have a higher frequency and longer duration of temper tantrums and longer recovery time.

CME Test