CrimeSolutions.gov

Additional Resources:

Practice Profile

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

Evidence Ratings for Outcomes:

Effective - More than one Meta-Analysis Juvenile Problem & At-Risk Behaviors - Aggression
Effective - One Meta-Analysis Juvenile Problem & At-Risk Behaviors - Anger Experience
Effective - One Meta-Analysis Juvenile Problem & At-Risk Behaviors - Self-Control
Effective - One Meta-Analysis Mental Health & Behavioral Health - Problem-Solving
Effective - One Meta-Analysis Mental Health & Behavioral Health - Social Competencies

Practice Description

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).

Meta-Analysis Outcomes

top border
Effective - More than one Meta-Analysis 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.
Effective - One Meta-Analysis 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.
Effective - One Meta-Analysis 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.
Effective - One Meta-Analysis 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.
Effective - One Meta-Analysis 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.
bottom border

Meta-Analysis Methodology

top border
Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 11974 - 1997401953
Meta-Analysis 21981 - 20106164

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.
bottom border

Cost

top border
There is no cost information available for this practice.
bottom border

Other Information

top border
Sukodolsky, Kassinove, and Gorman (2004) conducted subgroup analyses on age, gender, and severity of presenting problems. No relationship was found between the age of participants and the magnitude of the overall effect size. Gender was significantly related to effect size only in regard to the outcome of anger experience: as the number of boys per group increased, there were fewer improvements with regard to quickness of anger, intensity of anger, and the amount of time spent angry. No significant differences were found between mild, moderate, or severe problems and overall effect sizes. The researchers also examined differences across four types of CBT treatment: skills development, affective education, problem solving, and eclectic or multimodal treatment. They found that problem-solving treatments had the largest positive effect on anger experience. This statistically significant between-group difference showed that youth who participated in problem-solving treatments experienced greater improvements in anger experience, compared with youth who participated in the other three treatment types. Conversely, affective education had the smallest effect, or resulted in the least amount of improvement in anger experience, compared with the other three treatment types.
bottom border

Evidence-Base (Meta-Analyses Reviewed)

top border
These sources were used in the development of the practice profile:

Meta-Analysis 1
Sukhodolsky, Denis G., Howard Kassinove, and Bernard S. Gorman. 2004. “Cognitive-Behavioral Therapy for Anger in Children and Adolescents: A Meta-Analysis.” Aggression and Violent Behavior 9:247–69.

Meta-Analysis 2
Hoogsteder, Larissa M., Geert Jan J.M. Stams, Mariska A. Figge, Kareshma Changoe, Joan E. van Horn, Jan Hendriksa, and Inge B. Wissink. 2015. “A Meta-Analysis of the Effectiveness of Individually Oriented Cognitive Behavioral Treatment (CBT) for Severe Aggressive Behavior in Adolescents.” The Journal of Forensic Psychiatry & Psychology 26(1):22–37.
bottom border

Additional References

top border
These sources were used in the development of the practice profile:

Apsche, Jack A., and S.R. Ward Bailey. 2004. “Mode Deactivation Therapy: Cognitive Behavioral Therapy for Young People with Reactive Conduct Disorders or Personality Disorders Who Sexually Abuse. In: M.C. Calder (ed.). Children and Young People Who Sexually Abuse: New Theory, Research and Practice Developments. Lyme Regis: Russell House Publishing, 263–87.

Beck, Richard, and Ephrem Fernandez. 1998. “Cognitive-Behavioral Self-Regulation of the Frequency, Duration, and Intensity of Anger.” Journal of Psychopathology and Behavioral Assessment 20(3):217–29.

Bonta, James, and D.A. Andrews. 2007. Risk-Need-Responsivity Model for Offender Assessment and Rehabilitation. (User Report 2007–2006). Ottawa: Public Safety Canada.

Burraston, Bahr O., David J. Cherrington, and Stephen J. Bahr. 2010. “Follow-Up: An Evaluation of the Real Victory Program Reducing Juvenile Recidivism with Cognitive Training and a Cell Phone.” International Journal of Offender Therapy and Comparative Criminology 56:61–80.

Dodge, Kenneth A. 1980. Statistical Power Analysis for the Behavioral Sciences, Second Edition. Hillsdale, N.J.: Lawrence Erlbaum Associates.

Kendall, Phillip. C. 1993. “Cognitive-Behavioral Therapies with Youth: Guiding Theory, Current Status, and Emerging Developments.” Journal of Consulting and Clinical Psychology 61:235–47.

Lipsey, Mark W. 2009. “The Primary Factors That Characterize Effective Interventions With Juvenile Offenders: A Meta-Analytic Overview.” Victims & Offenders 4:124–47.

Schlichter, K. Jeffrey, and John J. Horan. 1981. “Effects of Stress Inoculation on the Anger and Aggression Management Skills of Institutionalized Juvenile Delinquents.” Cognitive Therapy and Research 5:359–65.
bottom border

Related Programs

top border
Following are CrimeSolutions.gov-rated programs that are related to this practice:

Equipping Youth to Help One Another (EQUIP) Promising - One study
This is a multicomponent treatment program administered in juvenile correctional facilities for youth with conduct disorders. This program is rated Promising. Program youth showed statistically significant improvements in social skills and had statistically significant fewer instances of self-reported and staff-reported institutional misconduct, compared with control group youth. However, there were no significant differences between groups on measures of moral judgment.

Aggression Replacement Training® (ART®) Effective - More than one study
A multidimensional psychoeducational intervention designed to promote prosocial behavior in chronically aggressive and violent adolescents using techniques to develop social skills, emotional control, and moral reasoning. The program is rated Effective. Among adolescents taking part in the intervention there was a statistically significant reduction in felony recidivism, improved social skills and a reduction in problem behavior among participants.

Aggression Replacement Training (ART) for Adolescents in a Runaway Shelter Promising - One study
A program that targets adolescents who live in a short-term facility (a runaway shelter) and exhibit signs of antisocial behavior problems (ASB). The program combines anger-control training, social skills training, and moral reasoning. The program is rated Promising. There was a 20 percent reduction in the rate of ASB incidents per client every week and a statistically significant reduction of 1.1 ASB incident per day.

Power Source Promising - One study
This is a group-based, cognitive-behavioral therapy and mindfulness training intervention targeted at male youth in high-security correctional facilities. The program is rated Promising. Results indicated a statistically significant reduction in the decline of attention skills for the treatment group, measured as accuracy and response variability on the Attention Network Test; however, there was no statistically significant effect on response time.

Juvenile Justice Anger Management (JJAM) Treatment for Girls Promising - One study
The program is a cognitive–behavioral, anger management treatment for adolescent girls in residential juvenile justice facilities, which is designed to reduce participants’ anger, physical aggression, and relational aggression. The program is rated Promising. Program participants showed statistically significant reductions in anger, physical aggression, and relational aggression scores, compared with the control group.
bottom border


Practice Snapshot

Age: 7 - 17

Gender: Both

Race/Ethnicity: Black, Hispanic, White

Targeted Population: Young Offenders

Settings: Correctional, Inpatient/Outpatient, Other Community Setting, School

Practice Type: Cognitive Behavioral Treatment, Conflict Resolution/Interpersonal Skills, Group Home, Individual Therapy, Violence Prevention

Unit of Analysis: Persons