Tantrums: Not Just the Terrible Twos Rachel J. Valleley, Ph.D. Assistant Professor, Munroe-Meyer Institute Licensed Psychologist

Behavioral Health Concerns in Primary Care Behavior problems ranked #1 by pediatricians (Arnorfer et al., 1999) Established link between medical and behavioral concerns (Wertleib et al., 1988) ADHD evaluations increased three-fold in 1990s (Hoagwood et al.,2000) In 24% of pediatric visits, behavior concern raised. Increases visit length from 11 to 17 minutes

Tantrums What are tantrums? – Screaming, crying, kicking – Pleading – Pointing fingers – Pouting

You are the meanest mommy in the world!

Tantrums Duration can be seconds to minutes typically Most common for ages 2 to 4 but can occur at any age (80% of children)

Tantrums Why do kids throw tantrums? – Frustrated with a task Trying to develop independence skills, do things on their own – To get what they want Tangible Parental attention – To get out of what they don’t want to do

I want, I want, I want

Pay Attention To Me

I can’t hear you so I don’t have to do it!

Tantrums Occur anytime, any place – At home – Store – Car

How parents feel after tantrums

When to be concerned about temper tantrums? Lasts for long periods of time Involves aggression Occurs frequently Causes distress to family Interferes with daily living

Tantrums Can lead to or be a sign of more serious difficulties – Oppositional Defiant Disorder – ADHD

Oppositional Defiant Disorder Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures that does not involve major antisocial violations. Frequently gets confused with ADHD. Can have both.

Oppositional Defiant Disorder: DSM-IV Criteria Loses temper Argues with adults Actively defiant or refuses to comply with adults’ requests or rules Deliberately annoys people Blames others for his or her mistakes or misbehavior Touchy or easily annoyed by others Angry and resentful Spiteful or vindictive

Oppositional Defiant Disorder Most common diagnosis given in our clinics in pediatric practices. Can be setting specific Occurring more with parents or other caregiver Difficulties with sleeping, eating, and toileting. Increased risk for other problems Dropping out, Abuse Coercive Family Process

Oppositional Defiant Disorder Misconception that “He’ll grow out of it”. – 67% at age 3 still have problems at age 9 Often leads to Conduct Disorders or antisocial personality disorder. Effective early intervention leads to long-term positive outcomes No medication that will effectively work

Oppositional Defiant Disorder Empirically-Supported Treatments: – Parent Training: Forehand & McMahon – Parent-Child Interaction Therapy: Hembree-Kigin & McNeil

Treatment for ODD: Parent Training 1. Encourage/increase appropriate behavior Differential Attention Child’s Game Sticker Charts/Grab Bag Prizes

Treatment for ODD: Parent Training Differential attention – Attend to average behavior – Praise exceptional behavior

Treatment for ODD: Parent Training The Child’s Game: A relationship-building activity that makes children want to earn your POSITIVE attention.

Treatment for ODD: Parent Training DO – Describe – Reflect – Imitate – Praise – Touch DON’T – Command – Reprimand – Question

Goal is to like each other again

Treatment for ODD: Parent Training Sticker Charts/Grab Bag Prizes: – Bedtime routine, morning routine – Daily for overall behavior – Magic circle chart – Dot-to-dot’s – Grab Bag Prizes

Treatment for ODD: Parent Training 2. Decrease inappropriate behavior Time out

Treatment for ODD: Parent Training What is time out? – Time out is the removal of attention, tangibles, or anything interesting to the child for a brief amount of time.

Treatment for ODD: Parent Training Common mistakes parents make – Talking to child in time out – Having time out be too long – Not having child do what is expected following the time out – Not expecting extinction burst

Treatment for ODD: Parent Training Common uses for time-out – Noncompliance – Aggression – Rule infractions – Tantrums

Summary Tantrums can be very distressing to parents Good idea to assess for tantrums, noncompliance – How often? – How long? – What causes tantrums? – How does the parent respond? – Is this behavior distressing to the parent? If problem exists, good idea to refer to behavior therapist Early intervention results in best outcomes