20. What causes temper tantrums in preschool-aged kids with Dr. Joyce Harrison

Temper tantrums can be so frustrating - for the child, the parent, the teacher, and everyone involved!  On episode 20 of PsychEd4Peds, Dr. Joyce Harrison, child and adolescent psychiatrist at Kennedy Krieger Institute/Johns Hopkins, shares with us an "8 S" framework for evaluating kids with temper tantrums. 

Q: What is on the differential diagnosis for a 4 year old with temper tantrums?

A: Thinking alphabetically, 

** A = ADHD, anxiety, and/or autism,

** C= communication difficulties, 

** D = developmental delay/intellectual disability, 

** T=trauma or adverse childhood experiences

Q:  What questions could the pediatrician ask the parent to sort through some of these possible issues?   

A:  It can be helpful to use the "Eight S framework"

§ 1 - Safety first

· Is this child safe?

· Are the people around this child safe? 

· Is this child safe to be treated in the setting that they're in? 

§ 2 - Specific behaviors 

· What is the child doing that makes the parent think something is wrong

· What is the most problematic thing? 

· What are you most concerned about?

§ 3 – Setting

· Where are the behaviors happening? (childcare/preschool, home, out w/ other people)

§ 4 - Scary/trauma 

· Has anything scary happened to this child/family? 

§ 5 - Services!!!!! 

· what kinds of services is the child getting now? (OT, PT, behavioral tx, meds)

§ 6 - Sleep

· How well are they sleeping? Any nightmares?

§ 7 - Social interactions

· Does your child have friends? 

· Does your child get invited to other things?

§ 8 - Speech problems

Dr. Joyce Harrison is an Associate Professor in the Division of Child and Adolescent Psychiatry at Johns Hopkins University School of Medicine. She is also on the Faculty at Kennedy Krieger Institute, a hospital serving children with developmental disabilities.  She is a nationally-recognized educator in early childhood mental health and its integration in primary care. She is the Project director for Kennedy Krieger Institute’s Early Childhood ECHO programs, and  Co-chair of AACAPs national Infant and Preschool Committee.  She served as the founding  Medical director of Maryland Behavioral Health Integration in Pediatric Primary Care program. She is President of the Association for Infant Mental Health, Maryland-DC chapter.

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to psyched for paeds, the child mental health podcast for pediatric clinicians. I'm your host, Dr. Elise Fallucco child psychiatrist and mom. In today's episode we're going to be talking about temper tantrums in preschool aged kids And our guest is going to share with us a helpful tool for gathering information from parents to better understand what issues could be causing temper tantrums or meltdowns so that we can help these kids early on. We are very fortunate to have with us, Dr. Joyce Harrison. Who is a nationally recognized child and adolescent psychiatrist who specializes in early childhood mental health and has worked extensively to help pediatricians integrate early child mental health into primary care. She's currently at Kennedy Krieger institute affiliated with Johns Hopkins and specializes in working with infants toddlers and preschool aged kids. Welcome Dr. Joyce Harrison!

Dr. Joyce Harrison: 1:20

Thank you, Dr. Elise. It's so wonderful to be with you today. Thank you for inviting me.

Dr. Elise Fallucco: 1:26

Oh, my gosh. I'm so excited to talk with you. So let's get started with a clinical case, because I want you to be able to share with pediatricians about how you think through differential diagnosis and evaluation for kids with temper tantrums and behavior problems. Let's say we have a four year old boy who presents to their primary care pediatrician as a new patient and his parent is complaining of frequent disruptive temper tantrums. Can you walk us through what's on your differential diagnosis for a four year old boy with temper tantrums?

Dr. Joyce Harrison: 2:01

one of the reasons I love working with this group is the challenge of seeing a behavior and teasing out what's underlying that behavior, because the differential is so broad. So this whole concept of diagnostic overshadowing, In the young age group, there's really just a limited repertoire of what they can present with. It's either temper tantrums, emotional dysregulation, sleep problems, aggression, they really don't have the bandwidth to do all of the other kinds to exhibit all the other kinds of symptoms that we see in older children and in adolescence. And there's many ways to these behaviors in this temper tantrums is one of the most common things that we see, but there's so many underlying and very often there's more than one underlying cause for those temper tantrum. So the list is pretty long. We think about-I'm just doing this in alphabetical order. ADHD,, kids with ADHD tend to have really low frustration tolerance and so they, they act out they lose it they get aggressive anxiety, and this is something that actually people don't. I think when they see a child having a tantrum that child might be anxious, some being faced to deal with the situation that you have to confront your fears or being forced to be in a situation that you're not expecting or, is out of the routine can set off kids who are anxious and they can tantrum as a way of trying to take control of the situation.

Dr. Elise Fallucco: 3:21

And Joyce, to your point about When we see temper tantrums, we forget to think about anxiety. What's helped me with that is just thinking about adults, like as adults, when we're nervous or when we feel out of control, we're much more likely to lose our temper or raise our voice or get angry. Just the same phenomenology in the kids.

Dr. Joyce Harrison: 3:40

It's so interesting, but it does get overlooked a lot. People don't see kids as anxious when they're externalizing their behavior. The other thing is autism, there could be, kids who have subtle symptoms of autism and we don't recognize it, but they might be tantruming. Kids with autism tend to have more prolonged tantrums and are much harder to soothe. So those, some of these things can be keys to when you see a child having a tantrum how quickly can they come down from it? And what's the intensity of it can also give you some clues, but autism is a big one.

Dr. Elise Fallucco: 4:07

So when you say prolonged, can you quantify that? Because as a parent watching your child tantrum, everything feels like a really long time.

Dr. Joyce Harrison: 4:16

So in a four year old about, three to five minutes is what you should expect. And beyond that, it really becomes not within the realm of normal.

Dr. Elise Fallucco: 4:24

You just shared an amazing clinical Pearl that I just want to stop and highlight. if you're seeing a four year old child in your office, who's having temper tantrums that consistently lasts a lot longer than four minutes and they seem to be very difficult to soothe afterwards. Both of those could be red flags or clues that you've got a major underlying problem that needs to be treated.

Dr. Joyce Harrison: 4:45

Yeah and the other thing, and this is an often forgotten or overlooked one is communication problems. Kids can have good vocabulary, but have problems with their receptive language, so they may hear something, think they're complying, then they're not, and then their parent may get upset with them, and then they tantrum because they're thinking, I'm doing what you told me, because what they heard is not what you said, and there's a miscommunication, so communication problems, uh, one of the most common developmental reasons that kids have Behavior problems, and those really do get overlooked because, as I said, you can have a kid who has good vocabulary and you think, oh, there's not a speech problem, also developmental delay intellectual disability those things can be subtle and having expectations beyond what a child can accomplish. Can lead to frustration on the part of that child and then a meltdown. And then the big one that I think very often gets overlooked is trauma and traumatic exposure. And, adverse childhood experiences because those children perceive threats where there aren't any. And so they may just get dysregulated and aggressive in a situation that doesn't seem to warrant it thank you. All of those things are all the things that we can see sometimes when we see. Tantrums and dysregulated behavior.

Dr. Elise Fallucco: 5:58

That's excellent. And I love how you alphabetized it, because we have to organize it some more. Yeah. So to recap, starting with the A's we've got three A's. ADHD. Anxiety and autism. And then we moved to C communication problems and don't forget receptive language difficulties there. And then D is for developmental delay or intellectual disability. And then we fast forward to T for trauma. I think it's really helpful to have this broad array of potential differential diagnoses. And I think when we see kids who tend to have a lot of activity and temper tantrums. It. Can almost be a reflex to diagnose ADHD. And it's a little bit harder to think about these other underlying issues or comorbid issues that could be happening as well. And i wanted to go back to something you said earlier you talked about the concept of diagnostic overshadowing can you tell us a little bit more about what you mean by that so

Dr. Joyce Harrison: 6:56

This is the idea that A behavior isn't always just a behavior that even though the symptom is a behavior, there can be many underlying causes. And what happens to overshadowing is We see the behavior and we address the behavior, but we miss the underlying. So that's the diagnostic overshadow. We miss the underlying contributing diagnoses, because as I said earlier, we see in our, in the children who come to us or the cases that we hear about in consultation, that there's more than one thing, they. They may meet criteria for oppositional defiant, which I didn't mention. But oppositional defiant disorder for me is just a waste basket descriptive that really doesn't help. I don't think in the 25 plus years I've been practicing, I've ever seen a child with only oppositional defiant. I think there's usually another diagnosis like ADHD or autism, or, something that may be more subtle. But the behavior becomes sort of a smoke screen for these other things that are going on because the behavior is so disruptive and so distressing to everybody, including the pediatrician in the office where the child's turning over chairs. And so that we just see behavior and parents sometimes see what I hate to hear what just a bad kid, but it's not usually that. In fact, more often than not, it's behavior plus or it's it's emotional, it's mental health, it's developmental. It's. All of the above. It's trauma. So we can't stop looking to figure out how to help these young guys.

Dr. Elise Fallucco: 8:22

Oh my goodness. Yeah. I could not agree more. We're quick to label these kids like, oh, he's like you said, he's oppositional. He's defiant. He's different.

Dr. Joyce Harrison: 8:31

He's difficult

Dr. Elise Fallucco: 8:32

or manipulative. Oh, yeah. Oh, yes.

8:35

I

Dr. Joyce Harrison: 8:35

don't like to hear that one. Yeah. So trying to see the behavior as a symptom of something else and not just bad behavior.

Dr. Elise Fallucco: 8:41

Absolutely. So you've given us this really beautiful alphabetical differential diagnosis for a four year old child with the temper tantrum. But can you share some practical tips or important questions that pediatrician should ask parents to help them sort through this differential diagnosis of temper tantrums

Dr. Joyce Harrison: 8:59

Some of the things that the pediatrician can ask the parent is, to notice where the behavior is happening when the behavior is happening. Again, what seems to set it off what seems to calm it down. Those more details about the behavior Actually. I like our eight S framework. Can I talk about the eight S? I

Dr. Elise Fallucco: 9:18

was hoping you'd talk about the eight S's

Dr. Joyce Harrison: 9:21

it's a tool that we use in multiple ways. A pediatrician can use it to get the information from the parent. We developed it when we were doing phone consultations with pediatricians. it was a way for us to streamline these consultations that we were doing. So we weren't taking up hours of the pediatricians time and then recommending things that they'd already tried. The first is safety because that's the first thing you want to make sure of is this child safe? are the people around this child safe? Is this child safe to be treated in the setting that they're in? So there's three aspects of safety. The second is specific behavior. So I found, Pediatricians would call me on the phone and say, this child's really anxious. And I would say, what is this child doing that makes you think they're anxious or that makes the parent think they're anxious? Because, we're always looking for target behaviors. What are the things that the child's doing? what are the most problematic things? Because sometimes what we think is most problematic, it's not what the parent. or the pediatrician thinks is most problematic. And so what are you most concerned about is a really good question to ask for that The third one is setting and setting is really important because in the early childhood world a child who's having, behavior problems in the classroom, but not at home might suggest that it's a problem with attention or it's a problem with learning. And so that's a clue. A child who's having problems everywhere maybe broader could also be ADHD but it could be anxiety, but it also could be, it's not as bad at home because the parents are accommodating the child and they're walking on their eggshells. And so the child doesn't get set off. Asking those kinds of questions about where the behavior is happening can really be helpful. School versus home versus child care versus with other people. And you know, you commonly hear this, my child's an angel with other people, Then, and that is so true but then you start thinking about, what's happening with the parent child relationship what's happening with discipline what's happening with all of the things and so that gives you clues in that direction.

Dr. Elise Fallucco: 11:16

A lot of the kids that I take care of often have problems in multiple settings. But if they're only in one setting, If kids are only having problems at school then you think about potentially something like learning disorders and then on the flip side if they're angels everywhere except for when they're at home that's when we think more about parent child relationship.

Dr. Joyce Harrison: 11:36

Yeah. And maybe some, traumatic events or stressful events in the home may be affecting the child's behavior too.

Dr. Elise Fallucco: 11:42

As a parent, it can be really frustrating when you hear that your child is an angel everywhere else, except with you. And I've seen this in my clinical practice. And I just want to say, I think some of this could be normal because if you think about it, when we're talking about very young kids, one of the only other places where they may be, could be a highly structured school environment. And so if you have a little kid who is bright, who does not have any communication or learning difficulties, then they can Excel in a highly structured school environment. Get rewarded and recognized. Whereas at home. It's nearly impossible for us to keep that level of structure. And

Dr. Joyce Harrison: 12:22

rewarding consistency. And, it's too, also, children with anxiety often respond really well to the structure and the consistency they have in the classroom. And then they come home and fall apart and the parents can't believe it when the teacher says, Oh, he did so well today. So it's, it is, the setting really can affect behavior. Especially in the younger kids. Because as we know, young kids just love structure and predictability. And as we also know, if you're a parent of a young child, it's impossible to have good structure and predictability sometimes. With all of the different competing things for your attention, so that's a challenge. So back to my S's, the final S is scary and scary really represents trauma. We had to come up with an S for trauma to ask about hard, scary, and difficult events surrounding the child or having happened to the child. has anything scary happened to this child? Or, ask the parents has anything bad happened to the family? Have there been any big changes in the family that have been hard for the family? So those were the five original S's but then I teamed up with my amazing partner, Mary Leppert, who I can't talk about anything without talking about her because it's our work together that has been so wonderful. and she's a neurodevelopmental pediatrician and her focus is on the role of, developmental problems in behavior problems and in young kids. she added three, these three S's because we heard sleep was a big problem all the time. Sleep, sleep is one of the presenting problems sometimes because when a young child's not sleeping, the whole family's not, their mom's not sleeping and it just creates this vicious cycle, but sleep. And also, sleep can be a clue to lots of other things that are going on, like trauma, anxiety, nightmares, all of that. And then we we ask about social and social interactions with the idea of looking for autism or other kinds of delays in social development or emotional development. We ask things like does your child have friends? Does your child get invited to other kids? Because kids who have ADHD often don't get invited to parties. So these, all of these can be little clues to your what your diagnosis, like what your diagnostic likelihoods are. And then speech, because as I said earlier, communication problems are probably the number one developmental comorbidity when we see these, because they're incredibly common.

Dr. Elise Fallucco: 14:36

So I was taking notes and I feel like I forgot an S, hold on.

Dr. Joyce Harrison: 14:39

Wait, safety, I probably forgot an F,, oh services, I didn't, I skipped services. Okay

Dr. Elise Fallucco: 14:44

I can count, I can still count. Okay, I'm sorry. Serious. Wait, let me do a little recap. Okay. So we talked about four, the first four S's, safety, specific behaviors, setting, and scary.

Dr. Joyce Harrison: 14:55

Yeah. What else? Services. I forgot services. And that was a hard lesson because as I said earlier, I would do a, I would spend half an hour on a phone with a pediatrician and I'd say, aha, you should do this. And they'd say, I already did that. So, I learned to be sure to ask, what kinds of services is the child getting now? Ask about. Behavioral therapy or services at school or previous medications.

Dr. Elise Fallucco: 15:19

Yeah I love this. So recapping B eight S framework that pediatricians can think about as they're going through a differential diagnosis with families and doing the evaluation. First, make sure that the child is safe. The parent is safe. Then focusing on specific behaviors and in which setting they occur. Ask about, if anything scary slash traumatic has happened, what services do they have in place? And then the last three S's are how's their sleep. Social interactions. And speech. And for those of you who are not taking active notes and trying to listen to this while driving your own child somewhere, I will have a version of this on our website at site for paeds. Dot com. Beautiful. And it's really easy. Those are like, it doesn't take a long time to ask those things and it tells you a lot. So. So as an overview and recap of this whole episode. When you see behavior problems in very young kids, think about the possibility of a wide differential diagnosis. And then you can use the eight SS to ask parents and families more information about these problems which can help you identify potential causes. With the ultimate goal of getting these children and families into early intervention services and help them to grow and develop in the most healthy way possible moving forward. We're going to continue this conversation with Dr. Joyce Harrison next week. And she'll be telling us about resources that pediatricians can use, and also things that we can do in the office to share with parents to help them help their kids. And if you're enjoying this podcast, We just asked you to take a couple seconds to do a few things that would help us greatly. If you could follow us bye clicking the plus button on our shows page. On either apple podcasts or Spotify or wherever you're listening to your podcasts. And if you wanted to leave a favorable review. That would be great too. If you enjoyed an episode, please share it with a friend or a colleague. All right thank you again for listening we hope you've enjoyed it and see you next time.