What to do with the angry toddler

By Morris Green, MD, Paula D. Sullivan, PhD, and Carolyn G. Eichberg, PhD

Clinical experience with 50 toddlers referred for worrisome displays of anger provides insight into why some young children behave this way, the pediatrician's role in evaluating and managing them, and preventive strategies.

The identification of psychosocial problems by pediatricians has increased dramatically in recent years.¹ Referrals to the Behavioral and Developmental Clinic at the Riley Hospital for Children in Indianapolis, Ind., have similarly risen. This article focuses on 50 children under the age of 3 years who were evaluated at the clinic between July 1, 1995 and June 30, 2000 because of the manifestations of anger described below. The behavior of these children was regarded by primary care physicians and parents as sufficiently troubling to warrant referral.

This age group is of special interest because behavior and child-rearing practices may not be ingrained yet; children are, generally, seen relatively frequently for health supervision or illness care; and intervention by a pediatrician may prevent further psychological morbidity. Evaluating this referred population provides the opportunity to better understand the causes of angry behavior in young children and to study the role of the pediatrician in their management.

Although the emphasis in the clinical experiences reported here was on the diagnosis and management of troublesome problems, an effort also was made to identify, retrospectively, how each child's problems might have been prevented through comprehensive child-health supervision that included: greater emphasis on family strengths and protective factors; early identification and, when possible, reduction of risk factors; broadened developmental surveillance; and monitoring of parent-child interactions.

Recognizing that mental- health services are time-intensive and generally inadequately reimbursed by third-party payers, the study also explored how questionnaires and checklists could facilitate diagnosis. That aspect of the study is still in progress.

Clinical manifestations

Because young children have a limited ability to verbalize anger and other feelings, they commonly express themselves through behavior in what may be termed their "second language" of affect. Angry infants may, for example, scream, hold their breath, flail about, scratch, shake their head, arch their back, or turn away when offered food.² Toddlers and preschool children, who at times express their anger verbally with such comments as "I hate you!", more often do so by holding their breath, throwing a temper tantrum, hitting, biting, pinching, kicking, fighting, whining, pouting, throwing objects, banging their head, pulling hair, spitting, marking on walls, cursing, making threats, being cruel to animals or destructive, crying inconsolably, trashing a room, climbing out of shopping carts and car restraints, running away outside the house or while shopping, being argumentative or stubborn, not complying with parental requests, talking back, and refusing to stay in bed at night.

In the patients we studied, these behaviors had often been present for months without the parents having attempted to identify the causes or seek professional help. Some parents attributed the behavior to a supposed medical disorder, such as "hyperactivity," "food allergy," or "chemical imbalance." Others regarded the behavior as willful and characterized the child as "spoiled," "hateful," "out of control," "high maintenance," "bad," or "having a meltdown" when told "No!" Two parents reported that they "walked on egg-shells" to avoid precipitating their child's anger. Anxiety and depression also were present in some children. In some instances, the child's expulsion from day care or preschool created a crisis, especially for a single parent who worked outside the home and had no other source of child care.

The "diagnostic" interview

Diagnosis and recommendations were based on data from questionnaires completed by the parents and child-care center or preschool, referral notes from primary care physicians, an interview, direct observation, and physical examination.

The interview was the most important source of diagnostic data and the most effective way to achieve the kind of physician-parent relationship required for acceptance and implementation of the recommendations. To save time and otherwise maximize the efficacy of the interview, parents were asked to complete and return a questionnaire before the consultation; excerpts are given in Table 1.

TABLE 1
From the parent questionnaire

What questions or concerns do you have about your child?

Any difficulties during pregnancy? Delivery?

Has your child ever had a serious illness?

At what age did your child first combine words?
Use sentences?

Is your child toilet trained?

How do you discipline your child?

How does your child get along with peers?
With siblings? Adults?

Check which of the following apply to your child:

What do you consider your child's strengths?

Who lives in your home?

In the past year, has your family experienced any of the following?

Father's age?

Mother's age?

Single?

Divorced?

Separated?

As customary in a pediatric interview, the parents were asked to talk about the chief complaints. This narrative was followed by supplementary "trigger" questions. For example, parents were often asked what they thought had caused their child's behavior ("While I realize that you may not know exactly, I'd be interested in what you think might be causing Michael to behave the way he does.").

Some parents expected a quick and simple remedy, as if the child had otitis media or streptococcal pharyngitis. Not recognizing a relationship between the behavior and the etiologic factors involved, they just wanted the problem fixed. Such expectations were reframed early in the interview with a statement such as: "In my experience, there's usually more than one reason for behaviors such as Michael's. It's my practice to review all relevant possibilities and then focus on those that seem to be contributing to the present problem. Toddlers can't tell us what's troubling them or why they act the way they do, so they communicate through their behavior. What do you think Michael is trying to tell you by his behavior?"

Another question posed when relevant was: "Our children sometimes remind us of someone in our family . . . the way they look, the way they behave. Who does Michael remind you of?" Several parents replied instantly that the child reminded them of a relative with a history of a conduct disorder or incarceration ("He is just like his [divorced] father!"). When an intergenerational history of violence, conduct disorder, or incarceration was present, the parent commonly worried that the child was predestined for a bad outcome ("Is his behavior inherited?").

Parents were asked about the circumstances in which the behaviors occurred or in which they were absent; who was present at the time; known precipitating factors; and recent major family changes or crises. Family violence and spousal abuse, alcoholism, and marital problems were highly significant contributors to symptoms in these children. This information was not usually volunteered in the parent's narrative, however, so it was asked about specifically when considered relevant: "Since domestic violence is so common today, I now ask about it routinely. Have you ever been in a relationship where you have been treated badly, threatened, or hurt?" "Who else in the family has a problem with anger?" "Does anyone in the family have a drinking problem?" Parents usually do not view such questions as intrusive when asked in a pediatric setting.³

The parents' narrative was supplemented by questions about other relevant risk factors, listed in Tables 2 and 3. In some cases, supplementary reports were available from home visitors, child-care workers, or preschool teachers. Checklists based on Tables 2 to 5 were also used routinely as diagnostic guides in the behavioral-developmental clinic.

TABLE 2
Risk factors in the child

• Difficult temperament (slow to warm up, resistant to change, difficult to comfort, irregular, easily frustrated, moody, irritable, impulsive, highly energetic, very sensitive and reactive)

• Language or speech delay

• Impaired hearing or vision

• Hyperactivity

• Low birth weight or has special needs (that is, less responsive and more difficult to care for than a full-term, healthy infant)

• Limited interaction with other young children

• Child abuse or neglect

• Multiple hospitalizations

• Multiple separation experiences

• Chronic illness, pain, movement restraint (e.g., cast), or other discomfort

• Frequent changes in family or caregivers

• Witness to domestic violence

• Poor mother-infant attachment

• Anxiety, depression

• Hunger, fatigue, overstimulation

• Mental retardation, autism, neurologic impairment

• Prenatal drug exposure

TABLE 3
Risk factors in the family

• Family violence; poor anger control

• Poverty, unemployment, financial problems, household crowding

• Fatigue, overwork, stressors

• Psychiatric illness

• Alcohol or drug abuse

• Child neglect or abuse

• Mother who seems cool toward a daughter or a son

• Parent unable to think of what she likes about the child or to report pleasurable interactions

• Divorce, separation, remarriage, death of family member

• Low parental efficacy, self-esteem, personal warmth

• Lack of experience caring for young children

• Attachment disorder

• Poor understanding of child development and behavior

• Parental disability or chronic illness

• Social isolation with lack of support

• Inadequate one-on-one parent-child time

• Inconsistent, harsh punishment or overpermissiveness

• Lack of a positive parental role model

• Belief that the child is destined to not do well

• Lack of help (especially for single working mothers)

• One or both parents' inflexibility toward reciprocity of child rearing

• Belief that the child's behavior is premeditated and intended to manipulate

TABLE 4
Protective factors in the child

• Secure attachment to parents; feeling of being loved and admired

• Pleasant temperament

• Unconditional positive regard by parent or other adult

• Self-regulated responses to stressful events

• Internalization of exemplary parental attitudes and behaviors

• Ability to express anger and other feelings verbally

• Ability to ask for help from parent or other adult

• Positive response to praise

• Pride in mastery

• Emerging understanding of cause and effect

• Confidence in making choices

• Early signs of empathy

• Interest in the social environment

• Positive peer relationships and day-care or preschool experience

• Ability to recognize and name emotions

• Ability to model appropriate expressions of emotions

• Effective communication of needs, desires, and feelings

• Adaptability to change

• Capacity for self-control and (at least) brief delay of gratification

• Ability to recognize somatic signs of discomfort

• Emerging ability to symbolize

TABLE 5
Protective factors in the family

• Healthy parents with high self-esteem and sense of efficacy

• Unconditional positive regard for the children

• Modeling and teaching of exemplary behaviors

• Commendation for acceptable behaviors; straightforward disapproval of unacceptable behaviors

• Good family communication and esprit de corps

• Knowledgeability about child development

• Physician for the child who provides developmental surveillance and mentoring

• Ability to interpret behavioral cues and respond accordingly

• Active listening to what children are saying

• Ability to ask for help and advice

• Supportive family, friends, groups, and community resources

• Chance to talk with other mothers about children

• Rewarding job or volunteer work (if desired)

• Supportive marital relationship

• Structured time and routines for eating, sleeping, dressing, bathing, and reading

• Parent-child individual time or shared with siblings doing what they enjoy

• Physical and social activities

• Siblings who are doing well

• Baby-sitters or mother's helper to provide respite for parents

• Parents who take time for themselves

• Ability to set limits

In addition to obtaining data and fostering a therapeutic physician-parent relationship, the interview provided an opportunity to directly observe the parents, the child, and their interactions. Are both parents present? Do they agree or disagree about their perceptions of the child's behavior and its causes? Do they explain to the child, as appropriate, what the doctor or nurse is going to do? Answer the child's questions? Praise her? Are they proud or disapproving? Warm? Cool? Supportive of each other? Communicate well?

Do they seem knowledgeable about the development of young children? Did they bring along a favorite toy or book for the child? A snack? Do they ignore, scold, yell at, or slap the child during the visit? Does the mother seem depressed or anxious? Are tensions present? Do the parents communicate openly with the doctor or are they intensely private?

During the consultation, does the child turn to the parents for comfort if tired or anxious? Ask questions? Relate comfortably to the doctor and parent? Seem trusting? Self-assured? Anxious? Uncomfortable? Angry? Hyperactive? Developmentally normal?

Management approaches

The behaviors presented by these children were viewed as outcomes of unplanned "experiments of nature," and the role of the pediatrician, one advocated by Milton Senn (a pioneer in advancing the psychotherapeutic role of the pediatrician), as that of a clinical investigator pursuing research of a kind. She (or he) observes patients, records observations, reflects on the findings, derives hypotheses, and forms predictions about the course and outcome of management. This approach is predicated on the belief that the more aware physicians are that clinical research work is in progress, the more skilled they become as interviewers and observers, the better their care, and the more rewarding they find these aspects of pediatric practice.⁴

It was not possible to change the socioeconomic and cultural factors that contributed to the anger in some of these families. But by identifying risk (and etiologic) and health-promoting or protective factors, physicians were able to personalize recommendations for disciplinary measures, make suggestions for reducing the number and influence of risk factors, and discuss augmenting family strengths. These strategies promoted the self-regulatory capacities and sense of comfort that help young children modulate their anger. Management was also enhanced by the use of community resources such as parent education classes, preschools, quality child-care centers, parent's day-out programs and support groups, mental health centers, and family counseling services.

Managing normal developmental variations

When complaints such as irritability, whining, or oppositional behavior occurred as a result of fatigue, hunger, overstimulation, or boredom, prospective intervention was advised. This includes giving the child a hug or a snack, reading a favorite story, watching a video, taking a stroll, working on a simple puzzle, playing quietly with blocks or Lego toys, or, if the child had fallen asleep riding in the car, gently transferring him to his bed.

In many instances, the parents did not understand the nature of the child's temperament, especially if an older child had had a pleasant, relaxed behavioral style as an infant. In these cases, clarifying and discussing the child's temperament was a highly relevant and important therapeutic intervention. Temperamentally difficult infants are not adept at regulating their mood or reducing discomfort on their own. Parents were told they could eliminate unnecessary frustrations by instituting predictable routines and consistent schedules (Table 6). Parents were also advised to:

• Ignore whining, sulking, or mild oppositional behavior.

• Offer choices ("The green shirt or the red one?" "Chicken nuggets or a hamburger?").

• Disapprove of minor sibling bickering or scuffling with a frown.

• Remove toys being used aggressively; offer diversion to a substitute activity.

• Recognize their child's interruptions as calls for the parents' attention and their child's growing frustration as a signal to intervene promptly.

• Avoid situations that require the toddler to work hard at managing his behavior when his energy is at low ebb.

TABLE 6
Dealing with the temperamentally difficult toddler: Suggestions for parents

Institute predictable routines and consistent schedules

Ignore whining, sulking, or mild oppositional behavior

Offer choices ("The green shirt or the red one?")

Disapprove of minor sibling bickering or scuffling with a frown

Remove toys being used aggressively; offer diversion to another activity

Recognize the child's interruptions as calls for attention and the child's growing frustration as a signal to intervene promptly

Avoid situations that require the toddler to work hard at managing his behavior when his energy is low

Parents were tutored to reinforce the appropriate expression of strong emotions: "I see that you are angry at Tommy, but I am very pleased that you did not hit him. I'm so proud of you!" (Recommending books such as those listed in the box on page 79 will both help the child understand feelings and encourage parents to read to the child.) With children who had a history of biting or hitting, parents or other caregivers were advised to maintain a proximal presence so that if such aggressive behaviors appeared imminent they could intervene promptly, moving the child, giving him a stern look, squatting down with a hand on his shoulder, or making eye contact and briskly interjecting, "No! No! Don't do that! Biting hurts!" Parents were instructed to offset these actions with increased parent-child play.

The needs of the child's siblings sometimes needed to be addressed as well. In such instances, the pediatrician offered to explain to the siblings how she is working with the parents to lessen the ways in which the "temperamental" toddler is disrupting family harmony and would identify the siblings' suspected emotional reactions by name, such as annoyance or resentment. The pediatrician also suggested compensatory extra attention for the sibling and special activities with the parents.

Complaints that the child was "out of control"

Management of patients with pervasive control difficulties was aimed at preventing escalation of angry outbursts to meltdowns. Parents were instructed to identify which specific situations routinely triggered the anger—mealtimes, for example, or awakening from a nap. Physicians then recommended pairing soothing objects or activities with these precipitating situations to diffuse the child's strong feelings. For example, cuddling with a blanket while listening to music allows a gentle transition from naptime. Parents were also instructed to prioritize their "battles" by distinguishing non-negotiable safety issues, such as whether the child rides in the car seat, from negotiable ones, such as which outfit to wear.

Parents were next instructed to identify the earliest warning sign that their toddler was disintegrating behaviorally. In many cases, parents did not recognize a distinct progression to rage episodes, instead describing a lightning, out-of-nowhere quality to them. Examples of warning signs described by parents were: "revving up" in a silly manner, bothering a sibling or pet, shadowing the parent, or repetitively voicing a request.

Such cues were to be interpreted as signs that the toddler was pushed beyond his temperamental ability to regulate himself. To avert a meltdown, the parents needed to engage the child in a pleasurable activity. If they were concerned that this implied "giving in" to misbehavior, the physician explained that this management strategy actually empowered the parents—allowing them to choose when, where, and over what issue the child would have a tantrum. They were further reassured that, ultimately, the child would learn how to settle down and control a portion of his feelings.

When parent-child interaction was lacking

An interview question that became almost routine was "How much one-on-one time have you been able to spend with Susan?" Many parents spent little such time with their child; some were overscheduled, others had not recognized its importance, and a few spent their discretionary time in social or recreational activities outside the home.

For parents who were interested in correcting this deficit, we recommended that they sit with the child with a large calendar in front of them, write in two or three 15-minute special times a week for some enjoyable, shared activity, and hang the calendar in a prominent spot. The "dates" provided a sense of intimacy and promoted the sharing of questions and feelings.

Improving family communication

Some parents were not sensitive enough to their child's feelings and not adept at reading behavioral cues—a kind of "affective dyslexia." Others rarely talked about emotions such as anger, anxiety, or even joy. Efforts were made to improve family communication and social linkages, to get the parents to listen actively to what the child was saying, and to have them name the suspected emotion: "Johnny, you seem kind of angry [worried, sad] about something. Tell Mommy about it."

Fluctuating moods and feelings, accompanied by a push for independence, often leave a toddler insecure. He needs to learn both that his grouchy or angry feelings are understood by Mommy and Daddy and that they can be trusted to react in a supportive way when he shares them.

Increasing praise, decreasing punishment

The importance of parental praise when the child is behaving well was repeatedly emphasized. For example: "Thank you very much for helping me." "Good job!" "We're so proud of you!" Other suggested rewards included hugs, kisses, stickers, games, special treats, fun activities, or books.

Parents were told that, although it was all right to show disapproval of unacceptable behaviors, they should eschew harsh punishment, screaming, blaming, nagging, and shaming with such words as "bad" or "stupid." Because of their depression or anxiety, some parents found this difficult to do.

When referral is indicated

Most children who presented with the behaviors discussed here could be successfully managed by a pediatrician who has the interest, skill, and time to do so. In some instances, however, consultation with, or referral to, a behavioral pediatrician, child psychiatrist or psychologist, marriage counselor, family therapist, psychiatrist, or community agency may be warranted for the child or one or both parents. Indications for a consult or referral may include chronic or severe family psychiatric or social morbidity (depression, bipolar disorder, alcohol or other substance abuse); multiple family risk factors (parental illness or disability, separation, divorce, incarceration, social isolation); domestic violence; harsh punishment of the child; reluctance of parents to change their child-rearing practices; and lack of improvement in the child's behavior with pediatric management (Table 7).

TABLE 7
Indications for a consult or referral

Chronic or severe family psychiatric or social morbidity (depression, bipolar disorder, alcohol or other substance abuse)

Multiple family risk factors (parental illness or disability, separation, divorce, incarceration, social isolation)

Domestic violence

Harsh punishment of the child

Reluctance of parents to change their child-rearing practices

Lack of improvement in the child's behavior with pediatric management

It may be helpful to develop a collaborative relationship with a clinical psychologist or social worker in the community. Their consultative role might focus on the toddler's emerging ability to symbolize his feelings through make-believe play as a tool to cope constructively with anger and aggression. In this way, the child learns that he has an outlet to express his anger and that he can act out his feelings in pretend play. When parents join him as play partners, he also has a valuable opportunity to feel warm, close, and understood.

Using time-out

Time-out was recommended as the most effective response to unacceptable aggressive behaviors such as hitting, biting, fighting, throwing toys, and disfiguring walls. Verbal instruction about the use of time-out was supplemented by a handout or book reference.^5,6 Additionally, it was explained that a parent's threats or screaming tend to reinforce misbehaviors by rewarding the child with attention, albeit negative, and that lengthy explanations or attempts at reasoning are ineffective in a child so young. Parents need to speak calmly and in simple sentences when a toddler is overwhelmed by intense emotions and his ability to think rationally is greatly compromised.

Children should learn to expect time-out as an immediate consequence of unacceptable aggressive behaviors. When these occur, the child is expected to go immediately to the designated time-out room or hallway and sit in the time-out chair for one minute for every year of age, up to 10 minutes. Parents were instructed that, if the child resists, they should gain control of their feelings and carry him to the time-out room; toddlers will only escalate their behavior if they detect anger pulsating through the parent's body.

Parents were also tutored about meeting the challenges that often occur in time-out, such as how to hold the child who is trying to escape from the chair and the importance of withholding attention and responding appropriately to the child's pleas to be released prematurely. They were advised to expect misbehaviors to increase transiently because it takes time for young children to make a connection between the time-out and the reason for which it was imposed. Parents were told to teach the child that time-out is used to help him regain control and is not simply a punishment for being bad. Time-out is much more palatable and growth-promoting when children learn to place themselves successfully in a quiet, soothing place away from the sensory overload so that they can reorganize.

Temper tantrums

Parents were advised to quietly wait out tantrums that occur in a place where the child cannot hurt himself but to keep the child within sight. Otherwise, they were to carry the child to a safe place. Some children will become more panicky if restrained, even if the parent remains calm, so parents were instructed how to "therapeutically restrain" their out-of-control child while stating, "I'm going to hold you until you calm down. I will not let you hurt me or yourself." [For more on this topic, see "When time-out fails, try Plan B" in the January 1998 issue.]

Parents should be told that extreme loss of control is scary for a toddler, who fears that his feelings will become so overwhelming and uncontrollable that he could destroy loved ones. For this reason, the child will feel even more anxious if the parent loses control.

Corporal punishment

Although controversial, corporal punishment such as spanking, hitting, shaking, shoving, or grabbing is believed to occur in most families. The use of these actions is determined by the family's culture; socioeconomic and educational status; how the parents were disciplined when they were children; religious beliefs; the child's gender; and the extent of the parents' fatigue, depression, anger, and stress.⁷ Authoritarian disciplinary measures, more likely to be used by parents living in neighborhoods that pose a high risk to a child's safety, may not be inappropriate within a secure, loving relationship. Some parents of the patients we studied, however, commented that spanking did not work for them, and they were interested in learning more effective measures.

Prevention and health promotion

The behavioral problems presented by the children in this study provided an opportunity to determine their etiology and identify useful therapeutic measures. They also prompted us to reflect on which preventive and health-promoting strategies introduced in a timely manner might have changed the behavioral outcome.

Although some of the children in this group were characterized as "high maintenance" by their parents, the reality is, of course, that the rapidly evolving physical, physiological, cognitive, social, and emotional development at this age makes all infants and toddlers high maintenance. This is a pediatric perspective worth sharing with parents—especially today, when the complexities of family life are troubling to toddlers and parents alike.

Optimally, child health supervision begins with a prenatal interview with both parents. A questionnaire requesting family health data mailed and returned before the consultation contributes to its efficacy. The prenatal interview allows the pediatrician the opportunity to answer parents' questions, obtain information about the pregnancy, inquire about the parents' expectations, identify family strengths and vulnerabilities, make observations, briefly discuss the philosophy of the practice, provide a brochure that answers commonly asked questions, and initiate a continuing relationship.⁸

In the prenatal and later interviews, the following screening questions may help identify family risk and protective factors pertinent to discipline: How was it for you when you were growing up? Do you intend to raise your baby like you were reared or somewhat differently? Were there any major changes or stresses in your family during your pregnancy?

The ninth- or 12th-month health supervision consultation visit, which occurs at a time when the baby is becoming mobile, is a good time to discuss parents' feelings about discipline. Emphasizing that discipline means to teach, the pediatrician may mention that this important responsibility is most likely to be successful when parents agree on their expectations, coach each other in refining their personal parenting practices, serve as behavioral models for the child, invest the time required, contain risks, and strengthen protective factors in their family.

Appropriate questions to ask at these visits include: How are you feeling these days? How is your family getting along? Have there been any major changes or stresses in your family since your last visit? How were you disciplined when you were growing up? How are you setting limits for Susan? How do you handle Scott's greater independence? What are your rules and how does Michael comply with them?

If there are no major risk factors in the child or family, parents will likely do well at raising their child if they agree on reasonable rules for safety and aggressive behaviors; use a consistent, command voice that firmly conveys the expectation of the child's compliance; show their disapproval of unacceptable behavior; enunciate "No!" firmly when indicated; and balance limit-setting with extra opportunities for closeness and communication.^9­13

The involvement of both parents and pediatricians is crucial to addressing the problems of the angry toddler. The box above summarizes key points in this article.

1. Kelleher KJ, McInerny TK, Gardner WP, et al: Increasing identification of psychosocial problems 1979­1996. Pediatrics 2000;105:1313

2. Sroufe LA: Emotional Development. The Organization of Emotional Life in the Early Years. Cambridge University Press, 1995, Cambridge, United Kingdom

3. Kerker BD: Identification of violence in the home. Pediatric and parental reports. Arch Pediatr Adolesc Med 2000;154:457

4. Senn MJE: The role of the clinician in behavioral research. Am J Dis Child 1965;109:272

5. Phelan TW: 1-2-3 Magic. Glen Ellyn, Ill., Child Management, Inc., 1995

6. Schmitt BD: Time-out: Intervention of choice for the irrational years. Contemporary Pediatrics 1993; 10(12):64

7. Smith JR, Brooks-Gunn J: Correlates and consequences of harsh discipline for young children. Arch Pediatr Adolesc Med 1997;151:777

8. Green M, Palfrey JS (eds): Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, ed 2. Arlington, Va., National Center for Education in Maternal and Child Health, 2000

9. Howard BJ: Discipline in early childhood. Pediatr Clin North Amer 1991;38:1351

10. Green M: Coping with the "helpless" parent. Contemporary Pediatrics 1997;14(11):75

11. Green M: Promoting parental "presence." Contemporary Pediatrics 1999;16(9):118

12. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health: Guidance for effective discipline. Pediatrics 1998;101:723

13. Schmitt BD: Discipline: Rules and consequences. Contemporary Pediatrics 1991;8(6):65

DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics editorial board.

DR. SULLIVAN is clinical assistant professor of pediatrics, Indiana University School of Medicine, and a member of the section on behavioral and developmental pediatrics, Riley Hospital for Children, Indianapolis.

DR. EICHBERG is a clinical child psychologist in private practice in Potomac, Md.

Reading list

Children's books

Alexander and the Terrible, Horrible, No Good, Very Bad Day, by Judith Viorst (New York, Atheneum, 1972)

Andrew's Angry Words, by Dorothea Lachner (New York, North-South Books, 1995)

Don't Rant and Rave on Wednesdays! The Children's Anger Control Book, by Adolph Moser (Kansas City, Mo., Landmark Editions, 1994)

Double-Dip Feelings: Stories to Help Children Understand Emotions, by Barbara S. Cain (Milwaukee, Wis., G. Stevens, 1993)

Feeling Angry, by Joy Berry (Let's Talk About Series) (New York, Scholastic, 1995)

The Mad Family Gets Their Mads Out: Fifty Things Your Family Can Say and Do to Express Anger Constructively, by Lynne Namka (Tucson, Ariz., Talk, Trust and Feel Therapeutics, 1995)

Mad Isn't Bad: A Child's Book About Anger, by Michaelene Mundy (St. Meinrad, Ind., Abbey Press, 1999)

My Many Colored Days, by Dr. Seuss (New York, Knopf, 1996)

Sometimes I Feel Like a Mouse: A Book About Feelings, by Jeanne Modesitt (New York, Scholastic, 1992)

Spinky Sulks, by William Steig (New York, Farrar, Strauss, and Giroux, 1988)

The Very Angry Day That Amy Didn't Have, by Lawrence E. Shapiro (Plainview, N.Y., Childswork/Childsplay, 1994)

When Emily Woke Up Angry, by Riana Duncan (Hauppauge, N.Y., Barron's Educational Series, 1989)

When I'm Angry, by Jane Aaron (New York, Golden Books, 1998) Accompanying parent guide to anger by Barbara Gardiner

When Sophie Gets Angry—Really, Really Angry . . . , by Molly Bang (New York, Blue Sky Press, 1999)

Where The Wild Things Are, by Maurice Sendak (New York, Harper & Row, 1984)

Parents' books

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, "Chronically Inflexible" Children, by Ross W. Greene (New York, HarperCollins, 1998)

Raising Your Spirited Child: A Guide for Parents Whose Child is More Intense, Sensitive, Perceptive, Persistent, Energetic, by Mary Sheedy Kurcinka (New York, HarperPerennial, 1992)

Raising Your Spirited Child Workbook, by Mary Sheedy Kurcinka (New York, HarperPerennial, 1998)

The tip of the iceberg

• The prevalence of the morbidity of psychosocial problems and the identification of those problems by pediatricians have increased significantly in recent years.

• This report reviews the presenting manifestations attributable to anger in children younger than 3 who were referred to a behavioral and developmental pediatric clinic over the past five years; the risk and protective factors identified in this population; the management of these children and their families; and the potential preventive role of the pediatrician through comprehensive health supervision.

• The immediate objective of our investigation is to improve the management of children who are brought to the pediatrician with behavioral manifestations such as those reported here. Beyond that effort, further delineation of the pediatrician's potential contribution to the prevention of mental health problems remains a substantial goal for clinical research.

 

Morris Green, Paula Sullivan, Carolyn Eichberg. What to do with the angry toddler. Contemporary Pediatrics 2001;8:65.