Aggressive tantrums may signify mental health risk.

Preschoolers whose tantrums consistently include self-injurious or outwardly projected aggression may be at risk of major depressive disorder, disruptive behavior disorder, or both, Andy C. Belden, Ph.D., and his colleagues reported.

"We propose that preschoolers who consistently exhibit the behaviors outlined may be in need of a referral to a mental health clinician for further evaluation," Dr. Belden and his associates concluded.

The investigators asked the parents of 279 preschoolers aged 3-6 years to complete the Preschool Age Psychiatric Assessment. The results enabled them to divide the children into four diagnostic categories: healthy (n = 150); major depressive disorder without comorbid disruptive disorders (MDD/no dis, n = 21); disruptive disorders without depression (DIS/no mdd, n = 54); and those with both depression and disruptive disorders (MDD/DIS, n = 54).

The investigators also grouped the children by tantrum characteristics: normative (tantrums that rarely escalated to excess); excessive tantrums without aggression (shouting, crying, and flailing, but no aggression); and excessive tantrums with aggression (self-directed, or directed at other people or objects).

The MDD/DIS groups and DIS/no mdd were significantly more likely than were the other children to engage in excessive tantrums. The MDD/DIS group also was nine times more likely than were healthy and MDD/no dis groups to engage in tantrums with violent or destructive aggression, while those in the DIS/no mdd groups were five times more likely to do so, wrote Dr. Belden of Washington University, St. Louis, and his associates (J. Pediatr. 2008;152:117-22).

Both MDD groups had significantly higher scores on destruction and self-injurious behaviors than did non-MDD groups. The MDD/DIS and the DIS/no mdd groups had significantly higher scores on oral aggression than did the other two groups. The MDD/DIS group also had a significantly longer tantrum recovery time and displayed significantly more tantrums in the home than did the other groups. The MDD/no dis group and MDD/DIS groups had significantly more tantrums in school.

Compared with children in the healthy group, those in the MDD/DIS group were six times more likely to be reported by caregivers as having difficulty recovering from tantrums.

"Healthy children showed significantly fewer violent, self-injurious, destructive, and orally aggressive tantrums than children with mood disorders, disruptive disorders, or both," the investigators wrote. "Furthermore, healthy preschoolers had less severe and shorter tantrums and required less recovery time.... Although replication of these findings is needed, results indicated that the 'anatomy' of a tantrum in healthy preschoolers was significantly different from same-age peers with mood disorders, disruptive disorders, or both."

The researchers cautioned that violent outbursts should not automatically trigger a psychiatric referral. About 30% of the healthy preschoolers also displayed some of these characteristics, and maladaptive behaviors in tantrums associated with hunger, sleep problems, or illness should not be considered alarming.

Nonetheless, they suggested that a consistent pattern of maladaptive tantrum behaviors should spark concern and a possible psychiatric evaluation.

The study was supported by a grant from the National Institute of Mental Health; none of the authors reported a conflict of interest.

BY MICHELE G. SULLIVAN

Mid-Atlantic Bureau