Abstract
I
Books such as Cognitive-Behavioral Therapy for Anger and Aggression in Children make it possible for child psychiatrists to incorporate CBT strategies into their practices for youth with anger management problems. Disruptive behaviors, including aggression and defiance, are among the most frequent reasons for outpatient mental health referral, and physical aggression is a frequent reason for psychiatric hospitalization. This book fills an important gap in the literature. Although there have been anger management programs for youths in groups (Feindler and Ecton 1986; Nelson and Finch 1996; Lochman et al. 2008), until now there were none for use in individual therapy. This program is for 8–16-year-old youth with significant problems with anger, aggression, and noncompliance. Each of 10 chapters outlines and describes an individual therapy session, each with a set of goals and alternative activities to meet each goal. The clinician is encouraged to select the activities that are most suitable for the developmental level and interests of the individual child. The suggested activities include carefully prepared worksheets and attractive illustrations to present the concepts. There are also three additional chapters that describe the three parent sessions that are part of the program.
The anger management program set forth is divided into three major modules, each of which parallels one of three major theoretical models of aggressive behavior. The first module is based on the emotional arousal model which suggests that physiological arousal and the intensity of angry feelings are related to overt aggression. Accordingly, the first session provides psychoeducation about anger and explores the situations that trigger anger for the individual child (which often includes being teased or bothered by a peer, told to do something by a parent while the child is engaged in an enjoyable activity, or being treated unfairly by a teacher), responses that often make the situation worse; that is, increase anger and/or result in a negative outcome (some form of physical or verbal aggression), and simple strategies to reduce angry feelings (i.e., engaging in a distracting activity or calming physical arousal by deep breathing). Session 2 emphasizes the importance of monitoring one's anger intensity by using a Feeling Thermometer and taking steps to prevent anger from getting out of control. Past situations are examined in order to come to the realization that intense anger clouds one's thinking and often results in negative outcomes. The Stop and Think technique is introduced, which is a visualization strategy intended to interrupt behavior (imagining a big stop sign or perhaps more effectively, imagining oneself sitting in the back seat of a police car). Additional calming strategies are introduced, including verbal reminders to calm oneself (“Take a deep breath” or “Take it easy”) and relaxation techniques. Session 3 expands on the concept of emotion regulation, introduces strategies to prevent anger-provoking situations from occurring, and further refines the recognition of one's own anger cues.
The second module is based on the social-cognitive model of aggression, which explains aggressive behavior as the product of cognitive deficits and distortions on the part of the aggressor. This theory is supported in large part by the findings of psychologist Kenneth Dodge (1980), who has demonstrated that aggressive children have a “hostile attribution bias;” that is, they are more likely than nonaggressive youth to perceive hostile intent in ambiguous situations, which in turn fuels anger. The three sessions in Module 2 focus on expanding the cognitive skills of aggressive youth by showing the connection between thoughts and emotion (how some thoughts fuel anger whereas others reduce or calm anger), improving their ability to identify the intentions and goals of other people (beyond hostile ones), and recognizing the existence and role of other people's perspectives in understanding social situations. This module systematically teaches problem-solving as a powerful strategy for dealing with frustrating situations, with aggressive behavior being only one of many possible options. The importance of keeping angry feelings in check is stressed during the problem-solving process, because of the detrimental effect that anger has on thinking skills.
The third module was influenced by social learning theory and the fact that aggressive youth have been shown to have weak verbal skills, poor conflict resolution skills, and deficits in skills that facilitate friendships. The last three sessions help aggressive youth to develop specific social behaviors that can be used instead of aggressive behavior in conflict situations with peers (Session 7) and authority figures (Session 9) by enhancing their assertiveness skills (Session 8).
The authors should be commended for providing the responsible caveat about whom the CBT program is not intended for, specifically youth with serious and persistent forms of criminal behavior such as weapon violence and drug use (which require more comprehensive interventions) and behaviors such as fire setting (which require specialized treatment). They are also forthright about the limited research on the outcome of their specific program. They report the results of one study of its application with 26 adolescents with disruptive behavior disorders plus Tourette's disorder. The CBT program produced significantly reduced disruptive behavior compared with a “treatment as usual” control group.
The authors are candid about the need for flexibility and clinical judgment in the delivery of the program, pointing out how some strategies such as relaxation training may not be well received by some in the targeted population, and they offer alternative strategies and activities to accomplish the same goals. The fact that most psychiatrists have had rather limited training in CBT may lead to more “trial-and-error” applications than is the case for other behaviorally trained mental health professionals. This CBT program will likely be more challenging to implement for psychiatrists than books such as What To Do When Your Temper Flares: A Kid's Guide to Overcoming Problems with Anger, which was written for 6–12-year-old children to be read with a parent, but which can easily be incorporated into therapy sessions (Huebner 2008).
Given the heavily behavioral orientation of the program, the most practical application of this book for child psychiatrists will be as a resource in their role as consultants to schools and mental health programs for youth with behavioral disturbances, to be used by school counselors, social workers, and psychologists in individual counseling sessions. Nevertheless, Cognitive-Behavioral Therapy for Anger and Aggression in Children is recommended to adventurous child psychiatrists who seek to expand their therapeutic armamentarium.
Footnotes
Disclosures
No competing financial interests exist.