Daily Dose of DrGreene

Temper Tantrums - When to Worry

Temper tantrums can be a normal and common part of early childhood, but sometimes they are a sign of a problem that needs to be addressed. Parents often ask me whether their child’s tantrums are beyond what is normal. When is a red-faced preschooler screaming and flailing about normal; when is the tantrum a cause for concern? What’s too often? What’s too long? What’s too extreme? Stay tuned for the top 5 reasons to be concerned. Researchers at Washington University School of Medicine analyzed the tantrums of 279 children from 3 to 6 years old. Their results will be published in the January 2008 Journal of Pediatrics. They divided tantrum behaviors into aggressive-destructive (kicking others, hitting others, throwing objects, breaking objects), self-injurious (hitting self, head banging, holding breath, biting self), non-destructive aggression (non-directed kicking, stamping feet, hitting wall), and oral aggression (biting others, spitting on others). The authors suggest that parents need not worry about isolated or occasional extreme tantrums, especially if the child is hungry, overtired, or ill. Instead, they should pay attention to “tantrum styles” – the overall pattern of tantrums. They identified 5 high risk tantrum styles and suggest that kids over age 3 with any of these deserve further evaluation by a mental health specialist. The results of the study are preliminary, and by no means proven, but at least give parents and pediatricians a place to start.

1. Aggressive tantrums. If a child shows aggression toward a caregiver or tries to destroy toys or other objects during most tantrums, the child may have ADHD, oppositional-defiant disorder, or another disruptive disorder. Specifically, if more than half of a series of 10 or 20 tantrums includes aggression to caregivers and/or objects, consider an evaluation. Depressed children may also have a pattern of aggressive tantrums.
2. Self-injurious tantrums. By the time a child reaches age 3, a pattern of trying to hurt oneself during a tantrum may be a sign of major depression and should always be evaluated. At this age tantrums that include behaviors such as scratching oneself till the skin bleeds, head-banging, or biting oneself are red flags no matter how long the tantrums last or how often they occur. In this study, they were almost always associated with a psychiatric diagnosis.
3. Frequent tantrums. Tantrums at home are more common than tantrums in daycare or school. Having 10 separate tantrums on a single day at home may just be a bad day, but if it happens more than once in a 30 day period, there is a greater risk of a clinical problem. The same goes for more than 5 separate tantrums a day on multiple days at school. In this study, when tantrums occurred at school, or outside of home or school, more than 5 times a day on multiple days, there was a higher risk of ADHD and other disruptive disorders.
4. Prolonged tantrums. A normal tantrum in this study averaged about 11 minutes (though I’m sure it seemed a lot longer to parents!). When a child’s typical tantrums last more than 25 minutes each, on average, further evaluation is wise.
5. Tantrums requiring external help. Kids who usually require extra help from a caregiver to recover from a tantrum were at higher risk for ADHD, no matter how frequent the tantrums were or how long they lasted. Speaking calmly to your child in the midst of a tantrum, or acting reassuringly, is normal. But if you find you can’t stop a tantrum without giving in or offering a bribe, pay attention. By age 3, kids should be learning how to calm themselves.

It’s normal for healthy preschool kids to have extreme tantrums sometimes, and to lash out at people or things on occasion. Starting to pay attention to tantrum styles rather than individual tantrums may help sort out what’s healthy and what’s not, and how to respond. What’s your experience with tantrums?

Alan Greene MD FAAP

Beldon, AC, Thomson NR, Luby JL. Temper tantrums in health versus depressed and disruptive preschoolers: defining tantrum behaviors associated with clinical problems. Journal of Pediatrics. 10.1016/j.jpeds.2007.06.030. January 2008.

How Much Dark Honey for Cough?

Nighttime cough is rough for kids and for parents. I’m not surprised that people spend billions of dollars on over-the-counter cough remedies, even though the most common ingredient, dextromethorphan (DM), has not been shown to be more helpful for kids than placebo. Now that the American Academy of Pediatrics and an FDA advisory panel have come out against the use of DM in kids under age 6, because of side effects, what’s a parent to do? It would be nice to have something that decreased both the frequency and severity of nighttime cough and increased sleep for both kids and parents. According to a study of kids from age 2 to 18 published in the December 2007 Archives of Pediatrics and Adolescent Medicine, honey may be one great solution. The children in the study had come into an acute care clinic with colds and coughs that had kept them (and their parents) up the night before. About one third randomly received artificially-honey-flavored DM cough syrups, about one third received real buckwheat honey, and about one third were given no treatment. In a three-way comparison, the honey scored the best in every category: reducing the number of coughs, reducing the severity of coughs, reducing the bother of coughs, increasing sleep for kids, increased sleep for parents, and combined symptom score. In two-way comparisons, only honey was significantly better than no treatment at all. The dose was ½ tsp in a single dose 30 minutes before bed for kids 2 to 5, a full tsp for kids 6 to 11, and two teaspoons for kids 12 to 18. The authors suggest choosing darker honeys as they contain more bioactive compounds. The study was done in Hershey, PA, reminding me that chocolate contains another remedy studied for coughs that proved better than DM. Given that DM can cause neurological side effects even at the appropriate dose, I’m a fan of trying gentle, food-based remedies like these.

Alan Greene MD FAAP

Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, and Berlin CM. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Archives of Pediatrics and Adolescent Medicine. 2007. 161:1140-1146.

Note: The authors of the study report that they were funded by the National Honey Board, an industry-funded agency of the USDA, who were not involved in study design or data analysis. The lead author has also been a consultant to Mcneil Consumer Healthcare, which makes cough/cold medicines for children.