Case #2: Grandmother and the Terrible Tantrums

A 3-year-old was brought in by their adoptive grandmother for “tantrums over everything.” The child’s screams and protests could be heard down the hall as the medical assistant tried to measure the child’s height and weight. Distressed, the medical assistant muttered, “What a brat,” before telling the provider the family was ready for their visit.

Entering the Provider’s world

What might be going through a provider’s mind?

• Overwhelmed: “How am I going to do this in 20 minutes? How am I going to be able to help?”
• Distressed, dysregulated
• “Righting Reflex”: “How am I supposed to fix this? This is out of my safety zone/out of my area of competence (I’m in medicine). What referral can I make? What handout can I give and move on? What advice do I have that can get me out of here?”

Grandmother shared that her grandson is having frequent tantrums—hitting, throwing, and screaming. He refuses to sleep in his own bed, won’t play on his own, and she can’t leave him in daycare or anywhere. His grandmother tried holding the door closed in his room, taking him back to his room, “swatting” him, and using time-outs, but his behaviors are getting worse.

Understanding the Behavior Concern

Provider: Start by listening and learning more about what is concerning the parent or caregiver.

Example questions to learn more:

• Quality – Describe what your child does that is a concern for you.
• Duration – Is this behavior new or has this been happening for a while?
• Triggers – Have you noticed are there any circumstances under which the behaviors occur?
• Alleviating – What have you and other caregivers tried to help the child? How has that worked?

The provider tried to understand more deeply by asking questions like:

• “How long has he been with you?”
• “What were some of the circumstances leading to his placement with you?”
• “Can you tell me a little more about his early life?”
• “What, if any, other family contacts does he have?”

The grandmother shared she was given custody due to parental drug use. The biological father, her son, had been put in jail the previous year. The biological mother had only briefly been present in early infancy.

The provider noticed all the grandmother is trying to do and validated her good intentions by saying something like:

• “Wow, you have really stepped up to help him.”
• “You seem very dedicated to his wellbeing.”
• “That’s quite a commitment as a grandmother how has this been for you?”
• “It sure sounds like you have tried a lot of things to try to help him already.”

While the provider was learning more about the behavior and situation, they were also observing the grandmother and child. The grandmother, with palpable anger toward her grandson, was in tears. The child was seated next to the grandmother, clinging to her arm, appearing fearful and crying. She resisted his clinging, telling him to “sit in your chair” and “stop crying” so she could talk.

Observations and Strengths Based Positive Feedback

Provider: Notice what the caregiver is doing well in their relationship with their child. Or in this case how the grandmother is really trying.
Provide positive feedback contingent upon what you observed or heard during the visit. Share why this is important for the child’s social emotional development. Or in this case you may be concerned about what you observe and recognize the need to support this family quickly.

Observe:
Temperaments of the caregiver and child
Emotional tone of the pair
Attachment behaviors of the caregiver and child (child seeking proximity and being able to become regulated by contact)

The provider asked, “How are you feeling when he is acting this way?”

Entering the Caregiver’s World

What might the caregiver be thinking and feeling?

Provider: Pause to be curious and suspend judgment. Ask reflective questions to learn more about the caregiver’s experience and to contain their distress.

The grandmother had recently been told by a friend that the child was trying to control and abuse her, like her late husband. She felt manipulated by her grandson and that she might be allowing herself to be victimized again now by the child’s behaviors.

She felt trapped and smothered by his clinging. She shared, “I need him to go to church school so that I have some time to myself. I feel afraid for the future and that he might be turning out to be like his father who had anger problems and is now in jail.”

The grandmother expressed feeling weak, ineffective, and exhausted by the power struggles. She felt frustrated and incompetent after her attempts at being more firm and consistent (advice from her friend) only made the behavior worse.

The provider asked the grandmother, “What do you think might be going on for him?” and “What do you think his feelings might be at those times?”

Entering the Child’s World

What might the child be thinking and feeling?

Provider: Ask reflective questions to learn more about the child’s experience

The grandmother answered, “He just wants to get his own way“.

The provider responded, “It can often feel that way. Young children do not always have words to tell us what they are feeling and may express them through their behaviors like crying, throwing, hitting or being clingy“

The provider then asked some additional questions to help the grandmother enter the world of the child and shared the handout “Challenging Behaviors of Infants and Toddlers”.

Example additional reflective questions and comments the provider asked and shared:

• “What sort of feelings do you think he might be having when he is acting this way”?
• “I wonder what his feelings might be at those times”
• I”m wondering if/what he might be trying to tell us about his feelings and needs during those times.”

The grandmother responded: “He doesn’t want to be left alone. He doesn’t want to be separated from me. Maybe he thinks I might leave him. I’m really all he has. I think he’s worried he might lose me.”

Identifying Caregiver/Child Needs

What might the caregiver and child be needing?

Provider: Now that you’ve learned about the caregiver and child’s underlying feelings, ask the caregiver to reflect on their own needs and the needs of their child.

The provider was able to help the grandmother recognize she needed more breaks and space for herself to be there for her grandson. She recognized her grandson needed to feel safe and secure. He also needed to learn words and acceptable behaviors for expression of his feelings. They both needed more delight or mutual enjoyment in the relationship.

The grandmother decided she could give him some “feelings” words to use and planned to watch closely to label emotions as she saw them to avoid larger “melt downs” She planned to tune into his cues and meet his social-emotional needs to feel understood and not alone with his feelings.

The grandmother decided to concentrate on positive statements throughout the day to reinforce the idea that she will always be there for him even when he doesn’t see her. ie “I had to go out of the room for a few minutes but I came back because I’m always thinking about you and will always keep you safe; She also planned to look for activities together they both enjoy” he liked to color and pretend play with his action figures – to restore delight and reciprocity in their relationship.

The grandmother planned to look for a familiar, supportive sitter/friend or preschool situation where he might feel comfortable so she could get time for herself to recharge. She also planned to start counseling.