When to get help
Most children have occasional tantrums or meltdowns. Acting out when it’s time to go to bed or stop playing a game is par for the course. But when kids are having tantrums often, or it seems like they can’t control their temper a lot of the time, you may be seeing something more extreme than typical problem behavior.
Here are some signs to look out for:
- When problem behavior is interfering with his ability to make friends or get along with other kids.
- When problem behavior is causing a lot of conflict at home and disrupting family life
- When your child feels like she can’t control her anger, and it is making her feel bad about herself
- When his behavior is causing trouble at school with his teachers or his fellow students
- When her behavior is dangerous to herself or others
If you are worried about your child’s behavior and are having a hard time managing it on your own, making an appointment with a clinician who has expertise in children’s mental health can be very helpful. A clinician can perform a comprehensive evaluation to determine whether your child may have an undiagnosed mental health disorder that is contributing to her behavior issues, or recommend specific strategies or treatments that might be helpful.
For more information about how to find a clinician who can help, read the Child Mind Institute’s Parents Guide to Getting Good Care.
Possible causes and diagnoses
Below is a list of some mental health disorders and other challenges that may be associated with disruptive behavior.
Attention-deficit hyperactivity disorder (ADHD)
Children with ADHD find it unusually difficult to concentrate on tasks, pay attention, sit still and control impulsive behavior. While disruptive behavior is not a symptom of ADHD itself, it is often the result of ADHD symptoms. Inattention and impulsivity can make it very difficult for kids to tolerate tasks that are repetitive, boring, or take a lot of effort. Because of this, children with ADHD are frequently overwhelmed with frustration, and throwing a shoe or pushing someone or yelling “shut up!” can be the result of their impulsivity. Some kids with ADHD can also develop negative behavior patterns, which are a response to years of finding themselves in conflict with adults.
Oppositional defiant disorder (ODD)
Children with ODD have a well-established pattern of behavior problems, with symptoms including arguing with authority figures, refusing to follow rules, blaming others for their mistakes, being unusually angry and irritable, and more. All children can have these symptoms from time to time. What distinguishes ODD from normal oppositional behavior is how severe it is, and how long it has been going on for.
Disruptive mood dysregulation disorder (DMDD)
Children with DMDD experience frequent, severe temper outbursts that seem grossly out of proportion to the situation at hand. In between tantrums they are chronically irritable. Their disruptive behavior is a result of their very big emotions and poor self-regulation skills. Children with DMDD often feel very apologetic after a tantrum is over.
Children who seem angry and defiant may be severely anxious. When children are having a hard time coping with situations that cause them distress, they may lash out. This may happen when the demands at home or school put a pressure on them that they can’t handle. In an anxiety-inducing situation, your child’s “fight or flight” instinct may take hold — she may have a tantrum or refuse to do something to avoid the source of acute fear.
Children who have been traumatized frequently mask their pain with behavior that is aggressive. As a result of their trauma they may be struggling with poor emotional self-regulation, negative thinking, and be overly alert to dangers — and more likely to jump into their “fight or flight” response in an effort to protect themselves.
Children who act out repeatedly in school or during homework time may have an undiagnosed learning disorder. They may be feeling frustrated and ashamed because they are struggling to do things that look easy for other kids, and they don’t know why. Rather than ask for help, they may rip up assignments or act out to create a diversion from their real issues.
Sensory processing issues
Some children have trouble processing the sensory information they are getting from the world around them. Children who are under- or over-sensitive to stimulation can often feel uncomfortable, anxious, distracted and overwhelmed, which can frequently lead to disruptive behavior.
Children on the autism spectrum tend to be rigid — needing consistent routine to feel safe — and unexpected changes can lead to them having a tantrum. Autistic children can also struggle with sensory issues that leave them feeling overwhelmed. Some autistic children may also lack the language and communication skills to express what they want or need.
Parent training programs
Parent training programs are designed to bolster the skills parents may need for managing a child’s problem behavior and improve the parent-child relationship. These programs are led by psychologists and social workers and are evidence-based, which means they have been thoroughly tested and found to be effective for many families.
Below is a list of different kinds of parent training, including what makes them different and which families they may work best for.
Parent-Child Interaction Therapy (PCIT)
Parents and children both participate in PCIT sessions, during which a clinician teaches them skills to interact in a positive, productive way. It is effective for kids between the ages of 2 and 7, and usually requires 14 to 17 weekly sessions.
In PCIT, parents receive live coaching (via a bug in the ear) from a therapist who watches from behind a one-way mirror as they and their child perform a series of tasks, and parents practice specific responses to both desired and undesired behavior.
Parent Management Training (PMT)
In PMT, which is for children ages 3 to 13, parents are usually seen without the child present, although children may be asked to participate in some sessions. Skills to deal more effectively with challenging behaviors are taught and modeled by the therapist and then role-played with parents. After each session, parents are expected to practice the skills at home. Families usually participate in at least 10 sessions.
Since PMT is appropriate for all ages, it’s a good choice when kids are too old for PCIT. It can also be a good option for families where the parent-child relationship is strong, but children might be struggling with things like anxiety, extreme impulsiveness or explosive anger.
Defiant Teens is for parents of teenagers who are 13-18 years old. The first half of this program involves only parents, and focuses on teaching more effective tools for interacting with their teenager, specifically for handling noncompliance or defiant behavior. But since teenagers are more autonomous than younger children and less influenced by their parents’ guidance, the program also includes training for the adolescent to help him become a participant in changing the family dynamic.
In the second half, parents and teenagers are both trained in problem-solving communication. The aim is to provide family behavioral resources to help each family member develop more effective problem-solving, negotiation and communication skills and to correct any unreasonable beliefs that might be impeding their interactions.
Positive Parenting Program (Triple P)
Triple P’s focus is on equipping parents with information and skills to increase confidence and self-sufficiency in managing child behavior. It can be utilized with a wide age range of children from toddlerhood through adolescence. With Triple P families can participate in different levels of intervention according to their needs. In some sessions clinicians will meet one-on-one with parents to discuss skills and strategies, and in some sessions kids with be included and the therapist will be provide live coaching.
The Incredible Years
The Incredible Years offers small-group-based training for parents of kids from infants through age 12. The programs are broken into four age groups (baby, toddler, preschool and school age) and they range from 12 to 20 weeks.
The program starts with a focus on improving parent-child relationships and positive attachment before moving on to consistent routines, rules and limit-setting. Finally it covers child management strategies such as ignoring, redirection, logical and natural consequences, time to calm down and problem-solving.
For children from four to eight years old, Incredible Years offers children’s groups that focus on helping them acquire emotion regulation strategies and social skills. Research shows that the kids’ group works well at improving pro-social behavior and decreasing problem behaviors. Parents find that they learn not only from therapists but from other fellow parents in the group.
Parent training and behavior therapy are considered a more effecting and longer lasting way to help children learn to manage their difficult emotions and rein in disruptive behavior. But medications are sometimes used as an adjunct to behavioral therapy. Anti-psychotic medications like Abilify (aripiprazole) and Risperdal (risperdone), which have been shown to reduce aggression and irritability, may be used in cases where a child is at risk of being removed from the school or home. Stimulant medication may be used if a child has excessive impulsivity, including those who have an ADHD diagnosis. Antidepressants (SSRIs) may be helpful if a child has underlying depression or anxiety.
It is important to talk with your doctor about any concerns you may have about your child’s treatment plan, progress or any side effects that you may be seeing. A good clinician will be ready to discuss the symptoms you are seeing and explain potential options for changing dosage or medication. If you don’t feel that your child’s doctor is taking your concerns seriously, or your doctor is not following best practices for changing dosage, or adding new medications, you should get a second opinion.
If you believe your child should stop taking a particular medication, make sure you tell your doctor, and discuss the pros and cons. Don’t make adjustments or withdraw the medication without consultation. Many medications should be reduced gradually, and children should be monitored for side effects of withdrawing too quickly.
Note about Risperdal
Risperdal can have serious side effects, including substantial weight gain and metabolic, neurological and hormonal changes that can be harmful. Children taking Risperdal or another atypical antipsychotic should be monitored by their doctors regularly over the course of treatment. Before treatment begins, they should be tested to establish baselines for height, weight, vital signs and levels of prolactin and blood fats and sugar. During the first few months of treatment, a child’s levels should be measured frequently. If the child is using the medication long-term, he should continue to be monitored on a yearly basis.