Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.

Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.

Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!

Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.

While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.

Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)

Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.

I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.

“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.

Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

Tips for assessing, managing temper tantrums