 |
 |
|
|
|
Behavioural problems are the most common problems presenting to children’s mental health centres (1). When left untreated, childhood behavioural problems characterized by anger and aggression can lead to increased rates of school dropout, juvenile delinquency, substance abuse, and poor peer relationships in adolescence (2–4). Therefore, it is essential that treatments that decrease anger and aggression early in childhood be developed. Programs for reducing anger and aggression are typically either community-based (5) or clinic-based (6). Many children in clinic-based programs demonstrate significant levels of anger and aggression, and untreated children may continue to have significant problems functioning during adolescence. Clinic-based programs can focus mainly on the child (7), the parents (8), or a combination of both (9). Evaluations of these programs have indicated that they are effective in reducing anger and aggression (10). However, limitations of these specific programs include the facts that they are time-intensive for participants and require intensive training for intervention facilitators. In this study, we conduct a pilot investigation of a short-term, cognitive-behavioural therapy (CBT) group program for anger and aggression that is designed to remove these aforementioned barriers to effective implementation and outcome. Effective clinic-based programs for anger management are essential, since anger and aggression are prominent in various mental health problems. Children with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), major depressive disorder (MDD), and several anxiety disorders have problems managing their anger (10,11). Excessive anger and aggression impact children’s academic functioning and peer and family relationships (2–4,10). Children with anger management problems are often in trouble with authorities at school and are frequently rejected by peers. At home, these children often receive negative feedback from parents. The negative feedback that children with aggression receive from parents, peers, and authorities often maintains their aggressive behaviour (12). Anger and aggression are interrelated constructs and may occur alone or simultaneously. In many instances, anger is a precursor to aggression (13) and can range in intensity from annoyance to rage. Aggression is a behaviour that can be verbal or physical, and hostility is an aspect of aggression that represents a covert form of attitudes, including resentment and suspicion (15). Anger and aggression also contain a cognitive component relating to the perception of an anger-provoking situation. Cognitive theories of emotions propose that cognitions representing the perceptions of events lead to emotions and that biased cognitions are typically responsible for strong, negative emotions (16). A child may feel hurt and then quickly angry, for instance, if he or she believes that a friend has deliberately ignored him or her (vs the friend did not see the child) on the schoolyard. Compared with nonaggressive children, children with aggression are more likely to interpret others’ ambiguous actions as hostile (17). Strategies to help children recognize when they are upset (that is, recognizing the experiential and physiological aspects of emotion), to help them become aware of common triggers for their upset, and to assist them in recognizing biases in their thinking should be useful in helping to reduce strong negative feelings. The goal of CBT is to help individuals first recognize and then challenge their biased perceptions. CBT may, therefore, be a particularly effective treatment modality for helping children reduce anger and aggression. Programs such as CBT, which target specific skills, appear to be more effective in reducing anger and aggression than eclectic programs (18). CBT has been shown to be an effective therapeutic treatment for children visiting clinics for help with anger and aggression (7,10). Kazdin’s Problem Solving Skills Training (PSST) program is an adapted CBT model, and significant research supports its effectiveness in reducing anger and aggression (7). PSST emphasizes problem solving in difficult social interactions and places somewhat less emphasis on understanding underlying feelings and cognitions. Consequently, it may not generalize beyond social situations. PSST is also lengthy, at 25 weekly sessions. This study involved a nonrandomized evaluation of the Temper-Taming Program (19). The Temper-Taming Program is an 8-week group CBT program that strives to reduce the incidence and intensity of children’s temper. The term “temper” is used with the children to help them recognize that there are more feelings than just anger that can lead to, and coexist with, anger and aggressive behaviour. We hypothesized that the intensity of anger and the frequency of aggressive behaviours in the children would decrease by the end of the program. More specifically, there should have been a reduction in anger, as reported on the Children’s Inventory of Anger (CIA), and in aggression, as reported on the Children’s Hostility Inventory (CHI), at posttreatment, compared with pretreatment. MethodParticipants Group Format Program Description The second step in reducing temper is to teach the children to problem solve when they recognize their first warning signs of temper. The children are taught to think through the consequences of their actions and that “choosing it” is better than “losing it.” “Choosing it” refers to selecting a response that is good for themselves and for others and that allows the children to get off the kNOw Problem Pathway and to eliminate current problems. The children are taught to brainstorm a list of alternative outcomes for each situation. By brainstorming and by having group members share actions that worked for them in similar situations, the children develop a list of positive alternative actions they can take. Examples of alternative choices include walking away from a conflict, asking a teacher for assistance, going to a quiet place to calm down, using a relaxation strategy, and negotiating a difference of opinion. “Losing it” and allowing temper to take over typically leads to more problems (for example, being suspended from school or being grounded at home); children who lose control of their temper lose control of their own lives when other people, such as teachers, principals, police, and (or) caregivers, get involved. Homework exercises are used throughout the group to help the children practise the kNOw problem process. In their last session, the children write down their alternative choices on a wallet-sized card. They are encouraged to keep this card with them at all times as a reminder to use what they have learned in the group. The children are also taught to recognize when their tempers may be increasing in frequency and severity (that is, when they are relapsing) and to identify a list of support people who can remind them to employ their strategies. Parents attend 3 parent group sessions to learn the same strategies the children are learning to assist their children in using their new temper-taming skills. The parents are also encouraged to notice and reward the positive choices their children make in controlling their temper and are referred to resources on behaviour management (for example, time-out techniques, withdrawal of privileges, or rewards and praise). Procedure Of the 68 children enrolled, 63 completed the groups. Reasons for not completing the group were as follows: parents did not complete the sessions (2/5), the family moved (1/5), the child felt too old to fit in (1/5), and the parent did not find the group to be helpful after the group commenced (1/5). There were no consistent, systematic data on the 5 children who did not complete the group; therefore, it is unknown whether their individual or family characteristics differed from those who completed the groups. For the remaining 63 children, some data were missing, owing to parent or child forms not returned or lost or to administrative error (2 in the pregroup, 4 in the postgroup, and 1 in both). Thus data on 56 children were available for analysis of at least one of the measures. Not all children had both the parent- and child-report measures administered or completed. Measures Children’s Hostility Inventory (15). The parents completed this 34-item questionnaire. Each item describes an aggressive behaviour, and the parents responded “True” or “False” to indicate whether the children demonstrated the behaviour. The CHI has 2 subscales: Aggression (17 items) and Hostility (14 items). The internal consistency of the entire scale is good (α = 0.82). The Aggression subscale assesses overt forms of aggression, and the Hostility subscale assesses covert, attitudinal forms of aggression. Validity for the 2 subscales is supported by their correlation with the Externalizing scale of the Child Behavior Checklist (21), with clinician ratings of antisocial behaviour and with teacher ratings of aggressive behaviour (15). ResultsWe focus on the 56 children who had both pre- and postscores on at least one of the measures. Table 1 presents by group the age range and sex of the 56 children included in the analysis. Attendance information was available for 53 of these children: 76% of the children attended all 8 sessions, and 100% attended 5 or more sessions; 94% of the parents attended at least 2 of the 3 parent sessions.
Correlations were calculated between the CIA prescores and the 2 CHI subscale prescores, Aggression and Hostility. CIA prescores did not correlate with the CHI-Aggression prescores (r= 0.08, P = 0.59), which suggests that the children’s ratings of their anger in response to specific anger-provoking situations is a construct distinct from their parents’ ratings of overt aggression. However, CIA prescores did correlate with the CHI-Hostility prescore (r = 0.31, P = 0.04), which suggests that the children’s ratings of their anger is a construct similar to their parents’ ratings of hostility or their covert attitudes, such as resentment and suspicion. There was also a significant correlation between the CHI-Aggression prescore and the CHI-Hostility prescore (r = 0.39, P = 0.003), which confirms that the 2 scales measure a related aggression construct. Mean scores on outcome measures are presented in Table 2. We conducted 1-tailed t tests to evaluate the hypothesized improvements on the 3 scales measuring anger, aggression, and hostility. Children reported that their level of anger (measured by the CIA) significantly decreased by the end of the group (t41 = 4.39, P < 0.0001). The effect size for this change was 0.69. In addition, the parents reported that the frequency of their children’s overt aggressive behaviours (measured by the CHI-Aggression) and hostility (measured by the CHI-Hostility) significantly decreased by the end of the group (t44 = 2.82, P < 0.01 and t44 = 4.93, P < 0.0001, respectively). The effect sizes for these 2 changes were 0.39 and 0.56, respectively.
Age, sex, leader experience, and leader’s professional background were not found to be significantly associated with decreased anger, overt aggression, or hostility at the end of the group, when analyses of covariance were conducted (results are not shown). We did not conduct an analysis of outcome by specific diagnosis (for example, ADHD or CD) owing to the small number of children in some categories. DiscussionThe Temper-Taming Program was found to be helpful in reducing children’s anger and aggression. Significant improvements on a children’s self-report measure of anger (CIA) and on parental ratings of children’s overt aggression (CHI-Aggression) and hostility (CHI-Hostility) were demonstrated. Retention and attendance rates were also good. Only 7% (5/68) of the children dropped out of the group, and attendance was strong, with over three-quarters of the children attending all 8 group sessions and all the children attending over one-half the sessions. The strong retention and attendance rates are encouraging, given that 40% to 60% of children in outpatient settings end treatment prematurely (22). Often, the children who drop out of treatment are the most difficult to treat (23). One explanation for the good retention and attendance rates is that the children enjoyed the group and learning exercises. Further, the skills being taught were simple and generalizeable to situations children encounter that typically trigger anger and aggression. The group format may have also increased retention and attendance rates because the children developed some positive relationships with other children in the group, under the guidance of the group coleaders. Since there is often a requirement for children to socialize in groups at school, in sports, and in community programs, the Temper-Taming group may recreate a real-life situation of working with peers with a positive outcome. Almost all parents attended at least 2 of the 3 parenting sessions. While this is good attendance, there is room for improvement to increase the number of parents who attend all sessions. The parenting groups were run in the evenings, and it is possible that there were barriers to attendance, such as child care responsibilities. These barriers may be further reduced by offering the program closer to the parent’s home or at the child’s school or by offering the program during the day, immediately after school, or on a weekend. This study was a pilot program and has some limitations. There was no randomization. In addition, longer-term follow- up would help determine whether the reduction in anger and aggression is sustainable over time. While there is some evidence that treatment effects for some interventions may be maintained up to 12 months later (24), this is not the case for all treatments. Given that we have no follow-up evaluation beyond postgroup, we are unable to know whether treatment effects were maintained among our group participants. Though it is optimal when successful clinic-based interventions generalize to show improvement outside the clinic, we did not specifically measure this. It is possible that, as the children continue to practise the skills learned in the group once the group is over, they will continue to reduce their anger and aggression over time. A booster session a few months after the group ends might remind the children to regularly use those skills learned in the group. Further research will help clarify who will benefit most from the group in terms of the severity of presenting behavioural problems, diagnostic category (from a structured diagnostic interview upon referral), treatment motivation, age, and sex. For instance, the children and parents who participated in this study may have benefited because they were motivated for change (25). This is likely not the case for some children with behavioural problems. The parents and children in this sample represent those who had come to a child psychiatry outpatient clinic for assistance and who had followed through on treatment recommendations by their clinician. Unfortunately, some parents and children with behavioural problems are not motivated to obtain assistance. Further evidence for the clinical significance of these findings requires more investigation and could be provided by finding similar results on measures that assess the children’s overall level of functioning at school, at home, and with peers. Obtaining reports of the children’s anger and aggression from multiple informants would also help to assess clinical significance. ConclusionsAttendance at the 8, 1-hour sessions of the CBT Temper-Taming Program is associated with reduced anger and aggression in children. The advantage of the Temper-Taming Program over other programs targeting anger and aggressive behaviour is that it is short; thus it is more likely to ensure treatment adherence and to reduce costs. Moreover, it does not require extensive training to run. References1. Offord DR, Lipman EL. Emotional and behavioural problems: frequency by age, gender, and income level and co-occurrence with other problems. In: Growing up in Canada: National Longitudinal Survey of Children and Youth. Ottawa: Statistics Canada; 1996. 2. Asher SR, Coie JD, editors. Peer rejection in childhood. New York: Cambridge University Press; 1990. 3. Cairns RB, Cairns BD. Lifelines and risks: pathways of youth in our time. New York: Harvester Wheatsheaf; 1994. 4. Loeber R. Antisocial behavior more enduring than changeable? J Am Acad Child Adolesc Psychiatry 1991;30:393–9. 5. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral intervention with aggressive boys. Psychology in the Schools 1989;25:179– 88. 6. Grizenko N. Outcome of multimodal day treatment for children with problems: a five-year follow-up. J Am Acad Child Adolesc Psychiatry 1997;36:987–97. 7. Kazdin AE, Bass D, Siegel T, Thomas C. Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior. J Consult Clin Psychol 1989;57:522–35. 8. Webster-Stratton C, Hollinsworth T, Kolpacoff M. The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. J Consult Clin Psychol 1989;57:550–3. 9. Kazdin AE, Siegel TC, Bass D. Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733–47. 10. Farmer EMZ, Compton SN, Burns BJ, Robertson E. Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. J Consult Clin Psychol 2002;70:1267–1302. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 12. Patterson GR. Coercive Family Processes. Eugene (OR): Castalia Publishing; 1982. 13. Finch AJ, Saylor CF, Nelson III WM. Assessment of anger in children. In: Prinz RJ, editor. Advances in behavioral assessment of children and families. Volume 3. Greenwich: JAI Press; 1987. p 235–65. 14. Nelson III WM, Hart KJ, Finch AJ Jr. Anger in children: a cognitive behavioral view of the assessment-therapy connection. Journal of Rational-Emotive & Cognitive-Behavior Therapy 1993;11:135–50. 15. Kazdin AE, Rodgers A, Colbus D, Siegel T. Children’s Hostility Inventory: measurement of aggression and hostility in psychiatric inpatient children. J Clin Child Psychol 1987;16:320–8. 16. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979. 17. Crick NR, Dodge KA. Social information processing mechanisms in reactive and proactive aggression. Child Dev 1996;67:993–1002. 18. Luk ES, Staiger P, Mathai J, Field D, Adler R. Comparison of treatments of persistent conduct problems in primary school children: a preliminary evaluation of a modified cognitive-behavioural approach. Aust NZ J Psychiatry 1998;32:379–86. 19. Mills B, Evans P. [Temper Taming Program Manual 1999.] Located at: the Chedoke Child and Family Centre, Hamilton. 20. Finch AJ, Eastman ES. A multimethod approach to measuring anger in children. J Psychol 1983;115:55–60. 21. Achenbach TM, Edelbrock CS. Manual for the Child Behavior Checklist and revised Child Behaviour Profile. Burlington (VT): University Associates in Psychiatry; 1983. 22. Wierzbicki M, Pekarik G. A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice 1993;24:190–5. 23. Kazdin AE, Mazurick JL, Bass D. Risk for attrition in treatment of antisocial children and families. J Clin Child Psychol 1993;22:2–16. 24. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76–85. 25. Prochaska JO, Velicier WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, and others. Stages of change and decisional balance for 12 problem behaviors. Health Psychol 1994;13:39– 46. Author(s)Manuscript received May 2003, revised, and accepted October 2003. 1. Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 2. Research Assistant, Child and Family Centre, Chedoke Hospital, Hamilton Health Sciences, Hamilton, Ontario. 3. Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. 4. Child and Youth Worker, Child and Family Centre, Chedoke Hospital, Hamilton Health Sciences, Hamilton, Ontario. 5. Family Therapist, Child and Family Centre, Chedoke Hospital, Hamilton Health Sciences, Hamilton, Ontario. Address for correspondence: Dr E Lipman, Chedoke Child and Family Centre, Patterson Building, Hamilton Health Sciences Corporation, Box 2000, Station A, Hamilton, ON L8N 3Z5 e-mail: lipmane@mcmaster.ca
1 | 2
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||