Temper tantrums, impulsivity, and aggression in a preschool-aged boy.

CASE. James is a 4-year-old boy whose parents had become increasingly concerned about his behavior since age 12 months. His mother described him as a high-needs infant since birth. He was colicky as a young infant, cried frequently, and was difficult to settle. His mother brought him to play groups after his first birthday; she had to leave early approximately half of the time because of James' aggressive behavior. James would often walk up to another child and punch him in the face for no reason. He also had problems with pulling hair and exhibiting long temper tantrums. James was the first child of parents with a stable marriage and a loving home. His mother chose to stay at home to care for James and was well informed about parenting techniques. At age 2 years, she discussed James' behavior problems with his pediatrician who suggested that she enroll in a parenting course. She complied with this suggestion, although she had already read many parenting books in her attempt to better understand and manage James' behaviors. At age 2.5 years, James' mother brought him to the pediatrician again, described his behaviors, and stated that she could not understand the reasons for his patterns of behavior. She told the pediatrician that there was no modeling for aggressive or abusive behavior in the home and that neither parent ever used physical punishment. She described periods of intense anger over relatively minor events during which James would clench his fists or shake with rage and strike out at those around him. Once again, she was encouraged to read parenting books, attend parenting classes, and use time outs for disciplining his behaviors. Between ages 2 and 3 years, James developed an attachment to dolls and carried a favorite Barbie doll with him everywhere he went. During this time, he also began frequent masturbation. He continued to strike out at playmates, often with no provocation. In frustration, James' parents took him to a child psychologist, who suggested that he had psychological issues that needed to be addressed and recommended three-times-weekly psychotherapy. The parents did not follow his recommendation. At age 3 years, he began preschool and was sent home nine times during the year for hitting others or for other unacceptable behaviors. His parents consulted a new pediatrician, who also suggested a parenting class. The family took James to another psychologist who performed a battery of psychometric tests. She told the parents that James had above-average intelligence, but problems with fine motor control, socialization, and sensory-motor integration, which would likely require treatment by an occupational therapist. She also recommended a structured behavior modification system, which the family found to be helpful. James was enrolled in a new preschool, where he was placed in a class with older children. A strict-but-loving teacher and consistent use of behavior modification techniques helped to decrease his unacceptable behaviors. James' behavior at home continued to be characterized by excessive crying and sudden outbursts of anger. James was taken back to his pediatriciar at age 4 years and was tested for allergies at the mother's request to find a medical explanation for his behavior. His physical examination was described as normal. His height was plotted at the 95th percentile for his age, and his weight was plotted at the 75th percentile. His relatively tall stature was attributed to the fact that his father is 6 feet, 3 inches tall. His allergy evaluation was normal. The pediatrician asked the parents to complete a questionnaire to screen James for attention-deficit/hyperactivity disorder (ADHD) as a possible explanation for his impulsive behavior. After reviewing the results of the questionnaire, neither James' mother nor his pediatrician believed that James met the criteria for the diagnosis of ADHD. James' parents were instructed to continue using behavior modification and were tol