Practice Profile: Cognitive Behavioral Therapy (CBT) for Anger-Related Problems in Children and Adolescents

Evidence Rating for Outcomes

Juvenile Problem & At-Risk Behaviors | Aggression

Juvenile Problem & At-Risk Behaviors | Anger Experience

Juvenile Problem & At-Risk Behaviors | Self-Control

Mental Health & Behavioral Health | Problem-Solving

Mental Health & Behavioral Health | Social Competencies

Date: This profile was posted on October 28, 2019

Cognitive behavioral therapy (CBT) is a problem-focused, therapeutic approach that attempts to help people identify and change dysfunctional beliefs, thoughts, and patterns that contribute to their problem behaviors. This variant of CBT focuses specifically on children and adolescents who have anger-related problems. The practice is rated Effective for reducing aggression and anger expression, and improving self-control, problem-solving, and social competencies.

Practice Goals/Target Population

Cognitive behavioral therapy (CBT) is a problem-focused, therapeutic approach designed to help individuals identify and change dysfunctional beliefs, thoughts, and patterns that contribute to maladaptive behavior. In general, CBT has been used to address a wide range of problems, including anger-related problems. (Beck and Fernandez 1998; Lipsey 2009). This variant of CBT focuses specifically on children and adolescents who have anger-related problems.

Anger-related problems in children and adolescents include aggression, self-control, problem-solving, social competencies, and anger experience. Aggression is often associated with violence and antisocial behavior, and youth who have severe aggression problems typically have other behavioral problems, such as conduct disorder (Hoogsteder et al. 2010). Aggressive youth are also more likely to have been arrested or convicted of a crime, compared with their non-aggressive peers (Andrews and Bonta 2010). For youth with anger problems, CBT is designed to 1) change how anger is experienced (e.g., how quickly a child becomes angry, the intensity of the anger, and the amount of time spent feeling angry), 2) reduce aggressive behavior, and 3) improve social functioning.

Practice Components

CBT may be provided through individual or group formats in a variety of settings, including at school, inpatient or outpatient centers, and juvenile correctional facilities. Length of treatment varies from 2 hours to 1 year. It utilizes a variety of therapeutic techniques to change the clients’ cognitive processes and behavior including modeling appropriate behaviors, recognizing cognitive distortions and problematic biases, building cognitive-coping skills, using rewards to modify behavior, rehearsing appropriate behaviors, and training in affective education (Kendall 1993). Further, these specific therapeutic techniques can be incorporated and delivered via a variety of treatment methods, including

Skills development, which targets overt anger expression and uses modeling and behavioral rehearsal to develop appropriate social behaviors
Affective education, which focuses on overt anger experience and includes techniques of emotion identification, self-monitoring of anger arousal, and relaxation
Problem-solving, which targets cognitive deficits and distortions and uses techniques such as attributional training, self-instruction, and consequential thinking
Eclectic or multimodal, which incorporates multiple procedures and targets two or more components of anger (Sukhodolsky, Kassinove, and Gorman 2004).
Mode deactivation therapy (MDT), which addresses the relationships among trauma, personality factors, and belief systems that contribute to anger and aggression (Apsche and Ward Bailey 2004).
Stress-inoculation therapy, which specifically focuses on anger related to stress, stress management, and coping skills (Schlichter and Horan 1981).
Cell phone therapy, which uses phone calls to monitor behavior and remind individuals of their goals during a cognitive training period (Burraston, Cherrington and Bahr 2010).

In addition, some CBT approaches include mindfulness exercises, which are aimed at reducing stress, while enhancing an individual’s consciousness in improving behavior.

Practice Theory

CBT is a behavioral approach designed to identify and change an individual’s maladaptive thoughts and behaviors. It is based on the cognitive model that describes how people’s distorted perceptions of situations influence their emotional, behavioral (and often physiological) reactions, which can lead to negative cognitions and maladaptive behavior (Sukhodolsky, Kassinove, and Gorman 2004). Dodge (1980) outlined a five-step sequential model of cognitive processes that consisted of 1) encoding of social cues, 2) interpretation or reception of cues, 3) response search, 4) response decision, and 5) enactment of behavior. Disruptions at any stage but particularly in the early stages, may lead to anger and aggressive behavior. Thus, CBT addresses problem behaviors by helping individuals to recognize and correct the flawed perceptions that may precede maladaptive thoughts and actions (Sukhodolsky, Kassinove, and Gorman 2004).

Juvenile Problem & At-Risk Behaviors | Aggression

Juvenile Problem & At-Risk Behaviors | Aggression
Across 36 effect sizes, Sukodolsky, Kassinove, and Gorman (2004) found a statistically significant mean effect of 0.63 for aggression, meaning that children who participated in cognitive behavioral therapy (CBT) for anger-related problems demonstrated lower levels of aggression, compared with control group youth. Similarly, across 6 studies (including 13 effect sizes), Hoogsteder and colleagues (2015) found a statistically significant mean effect of 1.139 for aggression, also showing that children who completed CBT for anger-related problems were less aggressive, compared with control group children.

Juvenile Problem & At-Risk Behaviors | Anger Experience

Juvenile Problem & At-Risk Behaviors | Anger Experience
Across 29 effect sizes, Sukodolsky, Kassinove, and Gorman (2004) found a statistically significant mean effect of 0.72 for anger experience, which was defined as how quickly a child reported that he or she became angry, the intensity of that anger, and length of time spent feeling angry. This finding indicated that children who participated in CBT for anger-related problems demonstrated significantly less physiological arousal under circumstances of being wronged or mistreated compared with control group youth.

Juvenile Problem & At-Risk Behaviors | Self-Control

Juvenile Problem & At-Risk Behaviors | Self-Control
Across 8 effect sizes, Sukodolsky, Kassinove, and Gorman (2004) found a statistically significant mean effect of 0.72 for self-control, showing that children who participated in CBT for anger-related problems demonstrated improved levels of self-control, compared with control group youth.

Mental Health & Behavioral Health | Problem-Solving

Mental Health & Behavioral Health | Problem-Solving
Across 11 effect sizes, Sukodolsky, Kassinove, and Gorman (2004) found a statistically significant mean effect of 0.73 for problem solving, meaning that children who participated in CBT for anger-related problems showed improved problem-solving skills, compared with control group youth.

Mental Health & Behavioral Health | Social Competencies

Mental Health & Behavioral Health | Social Competencies
Across 20 effect sizes, Sukodolsky, Kassinove, and Gorman (2004) found a statistically significant mean effect size of 0.64 for social skills, meaning that children who participated in CBT for anger-related problems demonstrated improved social skills, compared with control group youth.

Meta-Analysis Snapshot
	Literature Coverage Dates	Number of Studies	Number of Study Participants
Meta Analysis 1	1974-1997	40	1953
Meta Analysis 2	1981-2010	6	164

Meta Analysis 1

Sukhodolsky, Kassinove, and Gorman (2004) conducted a meta-analysis to examine the effects of cognitive behavioral therapy (CBT) for anger-related problems in children and adolescents. The researchers conducted a literature search via PsycLit, Medline, and Dissertation Abstracts International. They retrieved article abstracts by cross- referencing the following terms: “anger”, “aggression”, “oppositional behavior”, and “antisocial behavior” with “children”, “adolescents”, “treatment”, “therapy”, and “counseling”. Next, they manually examined references of individual outcome articles and meta- analyses of psychotherapy with children to find relevant titles.

Studies were eligible for inclusion if 1) a form of CBT was compared with a no-treatment or attention control condition; 2) treatment targets were explicitly stated and included one or more of the following: anger reduction, reduction of aggressive or antisocial behavior, improvement of anger-related, social-cognitive deficits, improvement of self-regulation or self-control, and improvement of social skills; 3) at least one outcome measure of anger or aggression was included; 4) participants were children and/or adolescents from 6 to 18 years of age; 5) study results were expressed numerically in a way that permitted the computation of effect size; and 6) studies were completed between 1974 and 1997 and reported in English .

Forty studies met the inclusion criteria. Of the 40 studies, 21 were published, and 19 were unpublished. Across these studies, 51 treatment versus control comparisons were used in the meta-analysis. Of these 51 comparisons, 41 were from studies that used random assignment, and 10 were from studies that did not use random assignment. A total of 1,953 children or adolescents participated in the studies. The average age of participants was 12.5, although mean age for the treatment groups ranged from 7 to 17.2 years old. On average, for each comparison, 82 percent of participants were male. Of the total sample, 41 percent of participants were in the moderate range of problem severity, 39 percent were in the mild range, and20 percent were in the severe range of problem severity. Treatment was delivered in various settings, including schools, outpatient centers, inpatient centers, and correctional facilities.

The 40 studies yielded 173 effect sizes. Instead of weighting, the researchers calculated three sets of effects: 1) overall effect per study or comparison, 2) effects per domain of measurement, and 3) effects per source of information. Effects were reported as Cohen’s d. The number of effects by outcome varied: the aggression outcome was calculated with 36 effect sizes, the anger experience outcome was calculated with 29 effect sizes, the self-control outcome was calculated with 8 effect sizes, the problem-solving outcome was calculated with 11 effect sizes, and the social skills outcome was calculated with 20 effect sizes. The researchers did not indicate what type of model they used for the analyses.

Meta Analysis 2

Hoogsteder and colleagues (2015) conducted a meta-analysis of cognitive behavioral treatment (CBT) for anger-related problems in children and adolescents. The researchers systematically searched the following electronic databases: PsycINFO, Medline, ERIC, Picarta, International Bibliography of the Social Sciences, Adlib, ScienceDirect, SpringerLink, ProQuest Dissertation Abstracts, and Google Scholar by cross-referencing the following keywords: “aggression treatment”, “anger-management training”, “chronic aggression”, “cognitive-behavior therapy”, and “externalizing behavior” with “adolescents”, “youth”, “juvenile”, “inpatient”, “incarcerated”, and “individual”. They then inspected all the references and citations of the articles found and inspected the reference sections of relevant systematic reviews and meta-analyses to find more studies that had not yet been included. Finally, they approached several researchers to obtain unpublished studies.

Studies published between 1980 through 2011 were eligible for inclusion if they met the following criteria: 1) addressed the effectiveness of treatments for adolescents with severe aggressive problems, often accompanied with conduct disorder (CD); 2) examined interventions that were individually oriented, which means that the intervention contained at least an individual component, possibly in combination with group and/or family therapy; 3) included CBT elements such as anger-management training, skills training, and cognitive restructuring; 4) provided posttest scores and a control group; 5) included a control group that received group therapy and/or individual treatment with no CBT elements; 6) included adolescents aged 12–18 years; and 7) provided the necessary data for the calculation of effect sizes. Studies were excluded if they specifically focused on prevention-based treatments designed for youth with conduct problems.

Overall six quasi-experimental studies were identified for inclusion in the meta-analysis. A total of 164 adolescents between the ages of 12 and 18 participated in the studies, which were conducted in both inpatient and outpatient settings. The average age was 15.8 years old, and approximately 63 percent of participants were male. In regard to race/ethnicity, 41 percent were Black, 24 percent were white, and 5 percent were Latino; however two of the studies did not provide information on cultural background. Approximately 74 percent of participants (n = 153) had a mental disorder, 64 percent were diagnosed with conduct disorder, 26 percent with oppositional de?ant disorder, 47 percent with a posttraumatic stress disorder (PTSD), and 30 percent had comorbid diagnoses. In two of the studies, the control groups received treatment as usual, which consisted of individual therapy with no CBT elements. In four of the studies, control groups received group therapy with elements of CBT.

The six studies yielded 13 effect sizes. Cohen’s d was calculated using the mean scores and standard deviations differences between the experimental group and the control group. Cohen’s d was adjusted for pretest group differences in the outcome variables. The researchers used a multilevel random effects model to calculate the combined effect sizes. The overall effect size was homogenous; therefore, the researchers did not conduct analyses to examine if moderators, such as gender or type of CBT intervention, had any influence on the outcomes.

Date Created: July 17, 2024

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Practice Snapshot

Age: 7 - 17

Gender: Male, Female

Race/Ethnicity: White, Black, Hispanic

Targeted Population: Young Offenders

Setting (Delivery): School, Other Community Setting, Inpatient/Outpatient, Correctional

Practice Type: Cognitive Behavioral Treatment, Conflict Resolution/Interpersonal Skills, Violence Prevention

Unit of Analysis: Persons

Practice Profile: Cognitive Behavioral Therapy (CBT) for Anger-Related Problems in Children and Adolescents

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