When a child is having a temper tantrum the caregiver should?

Almost all children have temper tantrums when they are toddlers. Temper tantrums are natural in children who are too young to express their anger and frustration in words. They are a normal part of child development and most frequently occur in kids between the ages of 2 and 3.

Temper tantrums range from whining and crying to screaming, kicking, hitting and breath-holding.

Children may even throw themselves down on the floor, clench their teeth, kick, hit and pound their fists. These emotional outbursts release energy as well as attract attention.

Boys and girls both have tantrums and your child's personality will also play a part. Some children are naturally easy going and positive, whereas others who are very active, intense and persistent may have more intense tantrums.

Some children are naturally easygoing and positive, whereas others who are very active, intense and persistent may have more intense tantrums.

Tantrums tend to occur more often if a child is anxious, ill, moody, tired or lives in a stressful home.

Causes of tantrums

Tantrums mean your child is overwhelmed by their feelings. It means they need your help.

To some extent, tantrums are attention-seeking behaviour. They often happen when children are tired, hungry or uncomfortable and want attention from parents or caregivers.

Frustration — children can get frustrated, especially when they can't get what they want. It's an unavoidable part of children's lives as they learn how people, objects and their own bodies work.

Poor verbal communication — tantrums are common at a time when children are learning to speak and can generally understand more than they can express.

Autonomy — children want a sense of independence and control over their environment. Sometimes when they attempt something, such as trying to open a container on their own, if they are unable to, it might be more than the toddler can handle.

Avoiding tantrums

Tantrums can’t always be avoided. But you can make them less likely by avoiding stress, identifying and anticipating what triggers them, and talking about emotions with your child. Here are some ideas to encourage positive behaviour in your toddler.

Reward and praise specific good behaviour — make sure your toddler gets enough attention when they are behaving well. When your child is behaving well praise them for that particular behaviour.

Choices — try to give your child some control and choices over little things. This may fulfill the need for independence and can ward off tantrums.

Encourage kids to use words — encourage your child to use words rather than screaming.

Reduce temptations — keep things you do not want your child to touch out of sight and out of reach to reduce the likelihood of struggles developing over them. This is not always possible, especially outside of the home where the environment cannot be controlled.

Distraction — take advantage of your child's short attention span by moving to a different environment, changing activities or offering them a different object.

Nurturing success — set your child up to succeed when your child is playing or trying to master a new task. Offer age-appropriate toys and games. Also start with something simple before moving on to more challenging tasks.

Know your child's limits — if you know your child is tired, or feeling unwell, it's not the best time to go to the supermarket or visit friends.

There is no point trying to reason with your child as they are not in control. Don’t punish or laugh at them.

• Stay with your child to help them feel secure. Be kind and reassure them. If your own feelings are getting out of control, move to another room but come back to your child when you feel better.
• Stay calm — don't complicate the problem with your own anger or frustration. Take deep, slow breaths and try to think clearly.
• Try to not get angry and don't resort to smacking or hitting your child.
• Ignore the outburst if the tantrum poses no threat to your child or others but remain in sight to prevent your child feeling abandoned.
• In public places or when the child is in danger of hurting themselves, pick your child up and take them to a quiet, safe place to calm down.
• Distract your child with another activity or change location.

After the tantrum

Do not reward your child after a tantrum by giving in to their demands. This will only prove to your child that the tantrum was effective. Instead, praise your child for regaining control.

Children may feel vulnerable after a tantrum when they may know their behaviour was not very desirable. This is a time for a hug and reassurance that your child is loved, no matter what.

You can talk to them about what they are feeling – jealous, scared or disappointed. Acknowledge those feelings and help them learn from what happened. Reassure them that you will always love them.

When to seek professional help

Most children outgrow the tantrum phase by the age of 5. If your child’s tantrums become more frequent, severe or destructive, it may be a sign of a bigger issue, such as stress, family issue or a health or development problem such as hearing problems, learning problems or difficulty with concentration or attention. Tantrums can also be a sign of anxiety or trauma in some children.

Consult your doctor or call Pregnancy Birth and Baby on 1800 882 436 for advice if:

• tantrums increase in frequency, intensity, or duration
• a child injures themselves or others, or destroys property during tantrums
• a child holds their breath and faints, or has a seizure during tantrums
• tantrums are accompanied by frequent nightmares, extreme disobedience, reversal of toilet training, headaches or stomach aches, refusal to eat or go to bed, extreme anxiety, constant grumpiness or clinging to parents
• tantrums persist when your child enters primary school
• you worry you might hurt your child or are stretched beyond the limits of your patience

Last reviewed: August 2021

Although temper tantrums are a normal part of development in toddlers, they can be distressing for caregivers and families. This activity describes childhood temper tantrums and the role of the interprofessional team in collaborating to provide optimal care for children and to advise caregivers and families on the healthy management of these events.

Objectives:

• Identify the epidemiology of temper tantrums.

• Outline the differences between typical and atypical temper tantrums.

• Describe how to manage typical childhood temper tantrums.

• Explain the importance of collaboration and communication among the interprofessional team to ensure that children with atypical temper tantrums are identified and appropriate psychiatric and/or developmental evaluation and intervention obtained.

Temper tantrums are brief episodes of extreme, unpleasant, and sometimes aggressive behaviors in response to frustration or anger.[1] The literature in older children refers to these events as "rages."[2] The tantrum behaviors are usually disproportionate to the situation. In toddlers, behaviors typically include crying, screaming, going limp, flailing, hitting, throwing items, breath-holding, pushing, or biting.[3] Tantrums occur once a day, on average, with a median duration of three minutes in 18- to 60-month-old children. The most common tantrum duration is 0.5 to 1 minute[4] with normalization of mood and behavior between episodes. The severity, frequency, and length of the events naturally decrease as the child gets older. Although the majority of temper tantrums in toddlers are typical and part of normal toddler behavior, atypical tantrums can be a presenting feature of behavioral and psychiatric disorders.[5] 

Common causes of sudden onset tantrums in toddlers are physiological triggers such as fatigue, hunger, or illness. Frustration is another common cause. Toddlers are conflicted due to a simultaneous desire for parental attention and a strong will to be independent. They have not developed mature coping skills to manage strong emotions. They also may learn that tantrums are an effective way to get what they want or avoid what they do not want in the short term. Also, toddlers learn through exploring their environment and may become frustrated when others prevent them from doing this, such as when an adult intercedes for safety reasons. As the child learns skills to identify their feelings, name emotions, communicate these feelings to others, and implement positive behaviors to manage negative feelings or emotions, the frequency of tantrums decreases.[1]

Tantrums most commonly occur between the ages of two and three but may occur as young as 12 months.[1] Researchers have found that tantrums occur in 87% of 18 to 24-month-olds, 91% of 30 to 36-month-olds, and 59% of 42 to 48-month-olds.[3] It is common for toddlers to have a tantrum at least once per day, as is the case for 20% of two-year-olds, 18% of three-year-olds, and 10% of four-year-olds. Five to seven percent of one-to three-year-olds have tantrums lasting at least fifteen minutes three or more times per week.[1] Children with language deficits or autism may have more frequent and aggressive tantrum behaviors because of the additional frustration associated with difficulty expressing themselves. Breath-holding events may occur during tantrums and affect 0.1 to 4.6% of otherwise healthy children. Breath-holding spells typically occur between six months and five years of age, with onset between 6 and 18 months, and disappear by five years of age.[6] There are no documented differences in the prevalence of temper tantrums by gender or race/ethnicity.

A thorough history and physical will help distinguish developmental, psychological, or physiological explanations for the tantrum(s) and determine whether the outbursts are atypical, warranting referral to a specialist. The provider should take a thorough history of the tantrums, beginning with an open-ended question such as, “tell me all about the tantrums.” A complete history may provide insight into family dynamics, allowing the provider to address parental behaviors that may be adjusted to manage the child’s behavior. The provider may also recommend that caregivers keep a record of the tantrums, which may help to elucidate patterns. The following is a list of questions the provider can ask for understanding the events before, during, and after the tantrum.[1]

• When do the tantrums occur (at what times of the day)?

• What circumstances precede the tantrum?

• What behavior(s) does the child demonstrate during the event?

• How long do the troublesome or undesirable behaviors last during the episode?

• What is the caregiver’s emotional reaction to the tantrum?

• How does the caregiver handle the tantrum?

• What are the child's mood and behavior between tantrum episodes?

• Have there been any changes to the child’s home or school circumstances?

• Has there been a recent move, change in family structure, or family conflict?

• Has anything scary or upsetting happened to your child or member of your family?

• Are there other behaviors that concern the caregiver or affect the child’s functioning, such as behavioral issues, sleep issues, anxiety, or loss of bladder control?

It is atypical for children older than five years to have a repeated pattern of tantrums. It is also unusual for a tantrum to last more than 15 minutes, or occur regularly more than five times per day. Extreme aggression is not typical of routine toddler tantrums. Consider a referral if the child or others are physically injured or the child destroys property during the outburst. If the child also has a sleep disorder, enuresis, or negative mood behaviors between tantrums, the child may benefit from a further medical, psychological, or developmental evaluation.

In addition to the history of present illness for tantrums, a thorough health history, including a developmental assessment, review of systems, and family history of behavioral and developmental disorders, should be obtained. Social history should include screening for social determinants of health and the identification of any trauma. Providers should discuss tantrums in the context of a health supervision exam, which is most pertinent at the ages of 12, 15, and 18 months and at two years when tantrums are frequent.

Physical examination of the toddler with tantrums is often normal. If the child has breath-holding spells during the tantrum, look for signs of anemia, such as mucosal pallor or tachycardia. [1]

No laboratory tests are needed to diagnose and manage typical temper tantrums. The physical examination is often normal.

Because visual or hearing deficits can cause frustration leading to tantrums, perform vision and hearing screening if warranted.[7] The United States Preventative Services Task Force states there is insufficient evidence to use instrument-based screening devices in children less than three years old.[8]

Lead neurotoxicity in children is associated with aggressive behavior.[9] Perform lead screening at 12 months of age for children living in areas with high-risk for lead exposure. If there are signs and symptoms of anemia or if temper tantrums are associated with breath-holding, obtain a complete blood count to assess for anemia.[6]

Standardized rating scales of childhood behavior for the evaluation of temper tantrums are usually not necessary in the community pediatrician’s office. There are rating scales available for purchase by pediatricians, researchers, and other child specialists for use in research and clinical evaluations of preschoolers. The Child Behavior Checklist and the Preschool Age Psychiatric Assessment are examples of instruments used with parents of children ages two to five years old.[10] The Preschool Feelings Checklist is a validated screening tool in the primary care setting for preschoolers in need of mental health evaluation and services.[11]

The child’s primary care provider can provide reassurance that tantrums are part of healthy child development, make recommendations for how to manage tantrums, refer when appropriate, or rarely, prescribe medication for associated extreme behaviors such as breath-holding or aggression. Prevention is the best way to handle frequent and recurrent temper tantrums, therefore attempting to mitigate common triggers of temper tantrums such as fatigue, hunger, illness, or injury can be helpful.[1] Iron therapy is effective in reducing the frequency and severity of breath-holding events in children with iron deficiency.[6]

There are times when caregivers cannot avoid a tantrum but can minimize their stress by practicing consistent management strategies. The acronym R.I.D.D. can help parents and caregivers handle a typical tantrum.

• Remain calm. State firmly "no biting" in a neutral tone. A quiet approach emphasizing redirection and distraction is useful. The statement “no biting” is appropriate to the developmental level of the toddler.   

• Ignore the tantrum.

• Distract the child. The caregiver may need to leave the room, building, or premises with the child and wait for it to stop.

• Do say “yes” when meeting the child’s physical and safety needs, but don’t give in to demands. Giving in to demands may reinforce undesired behaviors.

Time out may lose effectiveness if used too frequently. Children need frequent positive praise and encouragement. The American Academy of Pediatrics recommends a 1-minute "time-out" for every year of the child's age. Do not recommend physical punishment as it may cause tantrum behavior to increase in severity or duration. Physical punishment also teaches the child that hitting is permitted when angry or frustrated.[1]

Belden et al. identified temper tantrum styles that were associated with a higher risk of having a psychiatric condition.[5] These children display aggression consistently, are intentionally self-injurious, unable to calm themselves, or engage in tantrum activity for periods to time greater than 25 minutes. Children with these temper tantrum styles may benefit from a referral to a developmental pediatrician, child psychologist, or child psychiatrist.

It is helpful for the clinician taking care of young children to be knowledgeable of the parent training programs and resources in their community. Several parent training programs are available for parents to gain skills in managing challenging behavior. Parent-Child Interaction Therapy (P.C.I.T.) is an evidence-based intervention to decrease behavioral problems in children ages two through seven. Parents receive one-on-one and in-person coaching from a therapist behind a one-way mirror while they interact with their child in a set of tasks. Parents practice positive interaction skills and progress to disciplinary skills to improve the child’s behavior for 14 to 17 weekly sessions.[12]

Extreme, atypical temper tantrums are present in many behavioral, developmental, and psychiatric conditions. Consider disruptive, impulse-control, and conduct disorders such as oppositional defiant disorder, trauma-related disorders such as posttraumatic stress disorder, and neurodevelopmental disorders such as attention deficit hyperactivity disorder, autism, learning disabilities, and vision or hearing deficits.[1][5][13]

The prognosis for typical toddler tantrums is excellent. Providers should reassure parents that they are a part of healthy childhood development, and the child is expected to outgrow the tantrums by school age.

Tantrums do not cause cognitive or developmental abnormalities in the child. Breath-holding can accompany temper tantrums but is also benign.[6] Frequent temper tantrums can be disruptive to families and in some cases, in classrooms, leading to the anxiety of the parent or caregiver. If the tantrums are disrupting the class, parents should meet with the school educators and determine a plan for managing behavior. Bites sustained during the tantrum are usually superficial. Provide wound care and clean human bites with soap and water. If a child breaks the skin, the wound should be evaluated by a medical professional. Generally, the wound should not be closed or sutured, given the high risk for secondary infection. Antibiotic prophylaxis is warranted if the bite breaks the skin. The preferred treatment is empiric coverage of human and skin bacteria with amoxicillin-clavulanate for three to five days with close follow-up.

Prevention is the best way to manage frequent and recurrent temper tantrums. Fatigue, hunger, illness, injury, and frustration are common triggers of tantrums.[1] Use the acronym C.A.L.M. to remember the ways to prevent frequent tantrums and teach parents these skills:

• Communicate well. Model excellent communication skills and avoid yelling and arguing in front of the child. Ask the child about their feelings. Adults can provide examples of feeling words such as "angry," "sad," "tired," or "hungry." Offering facial depictions of feelings (such as a sad face, angry face, and happy face) allows toddlers to select the picture that best describes their feelings. Teach older children to express emotions verbally.

• Attend to the child’s needs. Give the child positive attention. Examples of positive attention include reading to the child, playing games, and including the child in routine activities such as cooking and cleaning. Caregivers can also avoid frustration by childproofing the home and offering age-appropriate toys that distract the child away from exploring unsafe or undesirable objects. Parental expectations of behavior should be age-appropriate. Limit childhood exposure to violent television viewing, which predicts adolescent and adult aggression.

• Let the child share their feelings and listen. Allow the child to control decisions by offering choices that would be acceptable to the caregiver. Avoid saying "no," too often. Unless it pertains to a health or safety issue, the caregiver may choose to let the child make a decision that may not be the preferred choice, such as wearing mismatched clothing. The child's or another's safety should not be put at risk by permitting the child's request.

• Make naptimes and mealtimes a daily routine as much as possible. If the toddler is away from home or misses their usual mealtimes, have simple, healthy snacks such as dried fruit or crackers available. Prepare children with expectations such as when bedtime will occur, or when there will be a change in activities.

While the pediatrician is almost always involved in the care of toddlers with temper tantrums, it is sometimes essential to consult with an interprofessional team of specialists that include may include a nurse, social worker, developmental and behavioral pediatrician, child psychologist, or child psychiatrist. If iron supplementation is part of the solution, a pharmacist should verify age-appropriate dosing, and report back to the prescribing clinician. To improve outcomes for atypical temper tantrums and aggression in the preschooler, prompt consultation with an interprofessional team is the recommended course. After referral, the primary care provider should schedule a follow-up with the patient as well as review notes from the encounter with the specialist. The problem list and medication list should be reconciled in the medical record with each contact to support interprofessional team communication with the most up-to-date and accurate health information. The key is to educate the parent that temper tantrums are benign. It is helpful for the clinician taking care of young children to be knowledgeable of the parent training programs and resources in their community. Several parent training programs are available for parents to gain skills in managing challenging behavior. Parent-Child Interaction Therapy (P.C.I.T.) is an evidence-based intervention to decrease behavioral problems in children ages two through seven. Child developmental experts recommend that prevention of temper tantrums is one way to avoid them; therefore attempting to mitigate common triggers of temper tantrums such as fatigue, hunger, illness, or injury can be helpful.

The long-term outlook for temper tantrums is usually excellent, and collaboration among members of the interprofessional healthcare team as outlined above, optimizes outcomes. [Level V]

Review Questions

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