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What does an ADHD tantrum look like?

Young children with ADHD are also extremely irritable — which can result in whining, demanding, or screaming every request they make — and prone to aggressive and angry outbursts. In the preschool classroom, students may whine if there are too many kids at the station or center where they want to play.

additudemag.com - When Toddler Tantrums Are Actually ADHD: Early Signs of ADD

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Some children exhibit signs of attention deficit hyperactivity disorder (ADHD or ADD) as young as 2 (and, in some cases, even earlier). Of course, disentangling normal Terrible Two behavior from ADHD is tricky, to say the least. Most toddlers have an abundance of energy, talk excessively, jump from one activity to another, and get distracted easily. They are impatient and howl over silly things — like getting the dark blue cup instead of the light blue one at lunch. The American Academy of Pediatrics says children may be diagnosed with ADHD no younger than age 4, but that doesn’t mean ADHD in toddlers isn’t real.1 There are real differences in the ADHD brain that are present at birth, and waiting too long to intervene may burden a child unnecessarily. It’s easy to spot children with severely hyperactive or impulsive behaviors — they’re the ones who are extremely active and spontaneous and seem to need less sleep than their peers. Their parents and caregivers are exhausted. But hyperactive behavior is not a hallmark of ADHD for all children; a better predictor for the development of ADHD is actually a child’s ability to regulate their emotions. Specifically, early negative emotionality (poor response to stress and a tendency to react with unpleasant emotions) is highly predictive of ADHD. The babies who may be at risk for ADHD are the ones who cry constantly and have trouble self-soothing; who are angry, fussy, and difficult to control; who have problems feeding and falling and/or staying asleep; or who are intolerant of frustration. When negative emotionality persists into toddlerhood, it looks quite different than a few typical toddler tantrums. Children with ADHD show more aggressive and emotionally intense behaviors when a prize is taken away from them. When presented with challenging tasks, such as puzzles with missing pieces, the young children with ADHD show more frustration, negative expressions, emotional outbursts, and anger than do their neurotypical peers. They are also quicker to give up.2,3,4,5 In short, toddlers and preschoolers with ADHD are overly reactive. Why? Because they feel emotions more deeply and hold on to them longer than do those without ADHD. They overreact with positive emotions, such as excitement, which can mean screaming and jumping for joy over small things (like when my daughter with ADHD ran around the house screaming like a maniac when I told her we were going for ice cream). They also overreact with negative emotions, disappointment, and frustration, which often lead to tantrums or aggressive behaviors. As neurotypical toddlers reach age 3 or 4 years old, they can begin, for example, to wait until after dinner for ice cream without having a major meltdown (though they may whine a bit if tired or stressed). Preschoolers with ADHD, however, cry or scream regularly over minor situations. “Small deals” are almost always “BIG deals” with these kids, and they show it with their emotional outbursts. Waiting is nearly impossible; they feel extreme pressure to get things now. Toddlers with ADHD tend to be easily frustrated, moody, and even rude. They may worry too much or too long about even the smallest of things and have more difficulty transitioning. They’re also extremely sensitive to corrective feedback – asking them to put on a coat to go outside can result in an angry scream. These children become overwhelmed with their feelings and have a hard time calming down. In the preschool classroom, students may whine if there are too many kids at the station or center where they want to play. Children without ADHD will generally move to another center. Children with ADHD, however, may drop to the ground screaming or push another child and tell them to leave. And not just once. Instances like these happen over and over. Preschoolers with ADHD tend to be more controlling and react with more hostility, anger, and aggression when upset and are more likely to get calls home than are their non-ADHD peers. When upset, young children with ADHD also tend to engage in tantrums that are more frequent, intense, severe, and disruptive than do other children their age. Typically developing toddlers may have weekly tantrums and parents can usually tell why the tantrum is happening (the child is likely tired or doesn’t want to do something). In toddlers with ADHD, the tantrums occur more frequently, last longer, and seem to come out of nowhere. The child’s reactions are excessive, completely disproportionate to the event, and/or inappropriate to the context. The tantrum can last for 20 minutes or more and the child has trouble calming down on their own and may even retaliate. Many will experience “full-blown” tantrums that they have zero control over — even if promised their most favorite thing in the world, they simply cannot stop.

Typical Toddler Behavior

Behavior Neurotypical Possible ADHD Tantrums 2-3 times/week for less than 15 minutes; frequency and intensity lessens over 6 months 3+/week for more than 15 minutes at a time; frequency and intensity persist for 6 or more months Aggressive behaviors (e.g., biting) 1-2 times/month (between 12-36 months) and/or with little expressive language 36+ months, occurring more than once or twice (i.e., often during tantrums), and/or possess good language skills Self-injury (e.g., bite or hit self, head-banging) n/a Occurs at any time When children with ADHD become over-stimulated (e.g., busy events or loud environments), their emotional reactions can be even more unpredictable and severe than usual. My daughter had emotional meltdowns at birthday parties and the worst of them always occurred at her own parties. It was just way too over-stimulating for her and resulted in screams, cries, throwing things, and demanding that everyone leave at once. She spent most of her fourth birthday party alone in her room while I led activities for her friends. Unfortunately, these youngsters typically receive a lot of negative feedback for their behaviors, which can contribute to low self-esteem, anxiety, and even depression. My daughter developed significant anxiety by the time she started school. She was the typical active child with ADHD early on. She developed all her motor skills early and was walking with a push car by the time other babies were just learning to crawl. She literally ran circles around the other babies and when she learned to talk, she didn’t stop (until she became a teenager).

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Naps ended early and we gave them up completely when she was 14 months, otherwise, she wouldn’t sleep at night. Even then I wondered how much she slept. We had to switch her to a “big girl” bed because she constantly climbed out of her crib. Because we couldn’t keep her contained, we would hear her banging around all night in her room. We removed her toys, but she amused herself by climbing the shelves in her closet. On more than one occasion, I found her in the morning sleeping in the closet. She was also a terrible eater who somehow grew normally though I was convinced she was starving because she couldn’t stop to nurse for more than two minutes at a time. She was way too impatient and needed to constantly look around the room.

And her emotional meltdowns? Epic.

I remember telling friends and family that the Terrible Twos were way worse than I had ever imagined (or saw based on my friends’ kids). I knew that behavior problems tend to peak at 2 years and then decline as they get older, but I found my daughter’s 3s were worse than her 2s. And, when I thought it just had to get better, the behaviors continued when she turned 4…. When was it going to stop!?

Many parents fall into this trap of waiting for behaviors to improve. Though it was clear my daughter was quite different from other kids, everyone told me to wait. They said she was just an active, imaginative, gifted child. So, we waited. While we waited for the hyperactive behaviors to go away, we overlooked the fact that she should have started showing more emotional control by the time she was 3. She was just a sensitive girl! More excuses. And then we ended up waiting too long. She continued to lash out emotionally, which interfered with her ability to build friendships and her self-esteem plummeted. I cannot overstress the importance of early intervention. Children who display emotional dysregulation — less frustration tolerance, more anger — are at great risk. And the more severe their anger outbursts, the more severe their ADHD symptoms tend to be. Similarly, dysregulated happiness is associated with greater inattention.6 Worse still, only about 40-50 percent of young children with ADHD receive the early intervention behavioral support they need. It’s important to know the early warning signs so we can help these kids as quickly as possible. Do not wait to see what happens. Begin logging your observations and concerns as soon as your baby is born. What’s fascinating is that babies actually start to show the ability to regulate their emotions within months of being born. For example, babies learn to look away from things that are upsetting them to self-soothe and control anger, frustration, and upset. Children with ADHD did not do those things as babies. As they move into preschool and their language capacity grows, typically developing children can better regulate their emotions and begin to respond to situations with flexibility and in socially appropriate ways. Children with ADHD, on the other hand, continue to have trouble managing challenging situations and reducing their distress. They cannot cope with negative emotions effectively and continue to vent (verbally or physically), show aggression, or engage in more avoidance behaviors to try and self-regulate. Our emotion systems develop earlier than our control systems. What’s more, the emotional brain is much stronger than the thinking brain (the one that helps us keep cool and make good behavioral choices). This means we must start supporting our kids by tapping into their emotional brain very early. The National Institute of Mental Health (NIMH) funded the Preschool ADHD Treatment Study (PATS) assesses the short- and long-term efficacy and safety of methylphenidate (Ritalin) in preschoolers (ages 3-5.5 years).7 Before starting the medication trials, all families completed an intensive 10-week behavioral therapy program, which included counseling supports for parents. One of the most significant findings from this study was that one-third of the children showed a significant reduction of ADHD symptoms after the behavior therapy program and, therefore, did not need to also receive medications. From that study, researchers concluded that behavior interventions designed to reduce symptoms of ADHD in preschoolers should be the first-line treatment for young children. The parent training component of behavior therapy is critical because parent behaviors influence children’s’ emotion regulation skills from an early age. Here’s how you can get started today. 1. Understand the ADHD brain. The brain continues to develop throughout childhood – a child’s thinking brain is the last to develop in adulthood. Further, when a child is upset, stress hormones are released into the body and all of the blood rushes out of the rational/thinking/calming part of the brain and into the motor cortex, preparing the body to either fight or run away. The emotional brain automatically takes over at this point, so any talking, scolding, punishing, or lecturing is useless because the brain that reads and interprets those messages is offline. It’s best to avoid engaging kids when they are upset. Get out of the heat! Give them space but stay close by so they don’t feel you are abandoning them. 2. Form strong bonds. As is true of any child, kids with ADHD benefit from strong caregiver relationships. They need to know they are loved and accepted no matter what. When we have strong bonds, we can strengthen positive and prosocial emotions, which helps with emotion regulation. Capitalize on small moments throughout your day where you can connect with your kids. Very important times are first thing in the morning and at bedtime. During these times, give them your full attention. Say something positive like, “I love seeing your sunshiny face first thing in the morning.” And smile! Always be on your child’s team. Teamwork helps build compassion — another strong prosocial emotion that builds the emotional brain.

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3. Be warm and responsive. Parents are most effective in supporting their kids’ emotion regulation skills when they are supportive, sensitive, and warmly responsive to their toddlers’ positive and negative emotions. Instead of reacting emotionally, validate their feelings. Saying “Hey, kiddo, I can see that your sister really upset you” is more helpful then demanding that they stop crying. Then create space to let them talk about what happened if they want to. If they don’t add more, or if they aren’t yet talking, create the space for them to cry, give you a hug, or whatever else they need at the moment. (Save learning about appropriate behaviors for a different time.) When we validate, we do not tell them “It’s no big deal.” It is a big deal to them and so when we say that we minimize how they feel and send the message that we do not want to hear how they feel. It’s important to calmly acknowledge that they are upset and let them know you are there to help. Kids react emotionally to create safety but also to be heard. When we create that space for our kids, they feel safe, heard, and understood. Showing empathy will help develop their empathy and they’ll learn they don’t need to react in overly emotional ways. 4. Highlight positive behaviors. Though it may not seem like it, your kids keep their cool all the time — we just take those instances for granted. Capitalize on these times by showing appreciation for doing the very things we want them to do, such as using their words for help or saying they are frustrated (vs. screaming and kicking). 5. Create opportunities. Talking to kids about our rules and expectations about keeping calm is not enough. Still, that is often all we do. We tell them what is expected, we send them off to play, and then we are exasperated when they scream 30 seconds later. Remember: they do not have the cognitive controls to keep it together in the heat of the moment. Instead, create opportunities for them to demonstrate how to ask for help when they are upset instead of getting frustrated and melting down. Create opportunities for independence. Kids who can learn to problem solve on their own learn to regulate behaviors on their own. What are the things they are fighting with you to do by themselves? It is likely time to let them take ownership. Create opportunities for mindfulness. We are finding more and more that mindfulness is important for emotion regulation and self-control. No child is too young to practice being mindful. Look for simple moments throughout the day — smell the dandelion they picked. Talk about what we feel and taste. Pet the dog and describe how the fur feels. Create opportunities to be a team. Feeling like they belong is another crucial part of building the emotional brain and there’s no better way to do this than making them feel like they belong on a team. My daughter is my favorite sidekick for just about everything, from going to the grocery store to walking the dogs to cleaning the bathroom. We talk about how we work together to get things done together as a team so we can go and have fun together. She likes to say, “we make a good team.” And we do. 1Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007‐1022. doi:10.1542/peds.2011-2654 2 Martel MM. Research review: a new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry. 2009;50(9):1042‐1051. doi:10.1111/j.1469-7610.2009.02105.x 3Olson SL, Bates JE, Sandy JM, Schilling EM: Early developmental precursors of impulsive and inattentive behavior: from infancy to middle childhood. J Child Psychol Psychiatry 2002; 43:435–447 4Shaw, P., Stringaris, A., Nigg., J., Leibenluft, E. (2014). Emotion dysregulation in Attention Deficit Hyperactivity Disorder. The American Journal of Psychiatry, 171, 176-293. 5 Steinberg EA, Drabick DA. A Developmental Psychopathology Perspective on ADHD and Comorbid Conditions: The Role of Emotion Regulation. Child Psychiatry Hum Dev. 2015;46(6):951‐966. doi:10.1007/s10578-015-0534-2 6O’Neill S, Rajendran K, Mahbubani SM, Halperin JM. Preschool Predictors of ADHD Symptoms and Impairment During Childhood and Adolescence. Current Psychiatry Reports. 2017 Oct;19(12):95. DOI: 10.1007/s11920-017-0853-z. 7Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry. 2013;52(3):264‐278.e2. doi:10.1016/j.jaac.2012.12.007 SUPPORT ADDITUDE To support ADDitude’s mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

additudemag.com - When Toddler Tantrums Are Actually ADHD: Early Signs of ADD

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