Evaluation of a short-term,cognitive-behavioral intervention for primary age children with anger-related difficulties

Abstract

This study evaluated the school-based short-term, cognitive-behavioral group anger management programme, ‘Learning How to Deal with our Angry Feelings’ (Southampton Psychology Service, 2003). Thirteen groups of children aged 7- to 11-years-old were randomly allocated to two different cohorts: One cohort (n = 35) first received the intervention and was then assigned to a no-intervention period; the other (n = 35) first had a no-intervention period and subsequently received the intervention. Both cohorts showed statistically significant improvements in their understanding of anger directly post-intervention, but neither reported improvements in self-perceived experience of anger scores. Teacher-rated measures of change in some problem behaviors (conduct problems and peer problems) showed significant improvements, but only in the second cohort (no intervention; intervention). The implications of these findings, and possible reasons for differences between cohorts, are discussed.

Keywords

Anger anger management cognitive behavior therapy conduct

Young people with Social, Emotional and Behavioral Difficulties (SEBD) are a particularly vulnerable group. Such children often lack appropriate social skills (Kavale, Mathur, & Mostert, 2004), and may have a negative attributional style or ‘hostile attribution bias’, whereby they interpret ambiguous social situations as threatening (see De Castro, Veerman, Koops, Bosch, & Monshouwer, 2002). They have limited behavioral repertoires, and may have little or no ability to control reactions to stressful situations (Lochman & Dodge, 1994). Reactions in such instances often involve aggression, and place the young people at particular risk of exclusion, both from schools (Achilles, McLaughlin, & Croninger, 2007; Cassen, Feinstein, & Graham, 2009) and, subsequently, from society (Christle, Jolivette, & Nelson, 2005; Cohen, 1998; Scott, Knapp, Henderson, & Maughan, 2001).

The underlying reasons for increased levels of anger in young people are complex. Children who develop this ‘hostile attributional bias’ may enter into a cycle of poor behavior, as the likelihood of eliciting negative reactions from others further reinforces this attributional style (Dodge & Pettit, 2003). Yet perhaps it is more interesting to consider what makes children develop this in the first place. While temperament is believed to be a risk factor in the development of conduct difficulties (Calkins & Fox, 2002), it is commonly agreed that this is mediated by environmental factors (Bates, Pettit, Dodge, & Ridge 1998; Dodge & Pettit, 2003). Children from families with low incomes, and particularly those in this group with a lone parent, are more likely to suffer from a range of emotional and behavioral problems (Meltzer, Gatward, Goodman, & Ford, 2000). By contrast, researchers have found decreasing levels of anger with increasing socioeconomic status (Turner, Russell, Glover, & Hutto, 2007). The reasons for this are multi-factorial, but are likely to be related to the extra stresses on families in lower income circumstances (which, in turn, can contribute to family instability and its consequences: Hirsch & Spencer, 2008) as well as sociodemographic factors (such as the more likely involvement with deviant peers in disadvantaged areas: Ingoldsby et al., 2006). Britain has one of the highest poverty levels in Europe (Child Poverty Action Group, 2009), and lone parenthood is an established feature of British society (affecting 25% of children; Hirsch & Spencer, 2008); behavioral difficulties among young people in the UK are on the rise (Collinshaw, Maughan, Goodman, & Pickles, 2004).

This increase in the incidence of behavioral difficulties, and need for strategies to support young people with anger and aggression, is mirrored internationally (Dodge, 2009; Edwards, Mumford, & Serra-Roldan, 2007). A number of targeted interventions have thus been designed to enhance or develop the social competence of children with SEBD and help them to control their reactive aggression. Examples include social skills groups (Benitez, Fernandez, Justicia, Fernando, & Justicia, 2011; Holsen, Smith, & Frey, 2008; Humphrey, Kalambouka, Wigelsworth, & Lendrum, 2010; Hutchings, Bywater, Gridley, Whitaker, & Gruffyd, 2012), parent collaboration (Quinn & Lee, 2007; Wilkinson, 2005), teacher collaboration (Baker, Clark, Crowl, & Carlson, 2009) and peer-mediated support (Desbiens & Royer, 2003). One approach that has a strong evidence base is individual or group cognitive behavioral therapy (CBT), particularly for targeting the anger and self-control issues often experienced by children with SEBD (Bennet & Gibbons, 2000; Sukhodolsky, Kassinove, & Gorman, 2004).

CBT-based anger management interventions are based on the premise that aggressive behavior is influenced by (1) heightened states of emotional and physiological arousal; (2) cognitive distortions including misperceptions of social stimuli and hostile attributions; and (3) poor social and problem-solving skills (Feindler & Scalley, 1998). Most of these CBT-based programmes therefore incorporate three elements: arousal management (looking at biological triggers and maintenance factors, and how to combat these); cognitive restructuring (addressing hostile attributions); and development of pro-social skills (i.e., developing constructive responses to anger: Boman, Smith, & Curtis, 2003; Sukhodolsky et al., 2004).

Although CBT-based anger management programmes have an extensive research base, with child, adolescent, and adult populations (Beck & Fernandez, 1998; Sukhodolsky et al., 2004; Yeo and Choi, 2011), there are clear gaps in the research. First, there is a paucity of empirical studies which focus on the effectiveness of cognitive-behavioral interventions for children with anger-related difficulties, as distinct from adolescents (Cole, 2008). Although meta-analytic findings indicate that there may be differences between the effectiveness of cognitive-behavioral interventions for the two groups (Bennett & Gibbons, 2000; Sukhodolsky et al., 2004), many empirical investigations continue to group together as ‘non-adult’, participants which span these two developmental stages (see, for instance, Kazdin & Wassell, 2000; Squires, 2001; Williams, Waymouth, Lipman, Mills, & Evans, 2004). Given the importance of providing early intervention for children with conduct difficulties, which can otherwise become entrenched over time (Moffitt & Caspi 2001; Rushton, 2003), there is a need to establish the effectiveness of cognitive-behavioral interventions for pre-adolescent children (Joughin, 2006).

A second gap in the research concerns the paucity of cognitive-behavioral anger management programmes which include a follow-up assessment, as a means of examining whether the effects of the intervention are temporary or sustained (van de Wiel, Matthys, Cohen-Kettenis, & van Engeland, 2002). While some researchers question the maintenance effects of cognitive-behavioral group interventions (Humphrey & Brooks, 2006), others report that effects are sustained (Broota & Sehgal, 2004; Muris, Meesters, Vincken, & Eijkelenboom, 2005; Whitfield, 1999) or, indeed, enhanced (Hemphill & Littlefield, 2001; Martsch, 2005) when follow-up assessments are conducted.

Third, many interventions are clinic-based and long-term (Sukhodolsky et al., 2004), notwithstanding the increasing importance accorded to school-based interventions for a range of socio-emotional and mental health difficulties, nationally in the UK and internationally (Department for Education and Employment, 2001; Green, Howes, Waters, Maher, & Oberklaid, 2005). Advantages identified for delivering interventions in schools include ecological validity (providing support within an environment in which problems may occur) and practicality (children are readily available, avoiding issues of transport and attendance; see Miller & Jome, 2010). Short-term interventions, if effective, are resource efficient, allowing more children to benefit from the skills which the intervention provides (Humphrey & Brooks, 2006).

This present study evaluates the efficacy of a short-term, cognitive-behavioral programme for groups of primary-age children with anger-related difficulties, ‘Learning How to Deal with our Angry Feelings’, developed by Southampton Psychology Service in the UK, in response to a rise in the severity and frequency of challenging behavior in local schools, and the resultant rise in exclusion rates. The programme formed part of a broader set of interventions, which included a more general curricular emphasis on emotional literacy as an equal partner to literacy and numeracy (Sharp & Herrick, 2000). As a school-based, short-term programme for pre-adolescents, it addresses many of the aforementioned gaps in the field of cognitive-behavioral interventions for anger and behavior management. However, while previous evaluations of this programme have involved broad measures such as school exclusion statistics (Faupel, 2006) and qualitative reports of intervention implementation (Sharp & Herrick, 2000), no data have been provided on the efficacy on the programme or its longer-term effects.

The purpose of this study was to provide an in-depth investigation of the programme and, by extension, to evaluate the efficacy of short-term cognitive-behavioral interventions for pre-adolescents with anger-related difficulties more generally. Specifically, this study aimed to address the following two questions. First, can short-term, CBT-based anger management groups for pre-adolescents produce both immediate and sustained improvements in participants’ understanding of anger as an emotional state and their self-reported experience of anger? Second, can short-term, CBT-based anger management groups produce both immediate and sustained improvements in teacher-rated problem behaviors (including emotional symptoms, conduct problems, hyperactivity-inattention and peer problems) and pro-social skills?

Method

Design

The study utilized a quasi-experimental, mixed-group design. Allocation of individual participants to conditions was not randomized: Each child was allocated to the anger management group operating within their school. However, schools were matched on the participants’ pre-intervention conduct scores on a teacher completed Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), and then randomly allocated to cohorts. Schools which received the intervention in Phase 1 of the study were labelled Cohort IN (intervention, no-intervention), while schools which received the intervention in Phase 2 were labelled Cohort NI (no intervention, intervention).

Measures were administered to both cohorts at three different points within the study: before either cohort received the intervention (Time 1); after the intervention had been received by cohort IN, but before it had been received by cohort NI (Time 2); and after the intervention had been received by cohort NI (Time 3). It was hypothesized that Cohort IN would show significant improvements on study measures relative to cohort NI between Time 1 and Time 2, and that scores for cohort IN would differ between Time 1 and Time 2, but not between Time 2 and Time 3, indicating maintenance following the end of the intervention. Additionally, it was hypothesized that scores for cohort NI would differ between Time 2 and Time 3, but not between Time 1 and Time 2.

Participants

Participants in this study were identified by their schools as experiencing difficulties with anger-related behavior. Children from 12 mainstream primary schools, who responded to information about the intervention from the educational psychology service in one English county, and for whom there was parental consent were formed into 13 groups. Group size ranged between four and seven children, for a total of 70 children (54 male, 16 female). Participants in the two cohorts did not differ significantly on any of following demographic variables: age (M = 9.71 years, SD = 0.95), ethnicity (90% White British), socio-economic disadvantage (21.4% were eligible for free school meals) and special educational needs. A majority (70%) of the children had special educational needs, with external agency involvement in 41% of cases. The most common special needs category was Behavior, Emotional and Social Development. This incorporates those children who demonstrate features of ‘emotional and behavioral difficulties, who are withdrawn or isolated, disruptive and disturbing, hyperactive and lack concentration; those with immature social skills; and those presenting challenging behaviors arising from other complex special needs’ (DfES, 2001, p. 87). In addition a medical diagnosis had been received by seven children: Three for Attention Deficit Hyperactivity Disorder, two for Autistic Spectrum Disorders and one each for Hearing Impairment and Tourette’s syndrome. Schools had been asked not to refer children with a diagnosis of Autistic Spectrum Disorders, as recent research has found that such children need special adjustments in order to benefit from a cognitive-behavioral intervention (Sofronoff, Attwood, Hinton, & Levin, 2007). However, two children were diagnosed with Autistic Spectrum Disorders during the course of the research. These children were excluded from the statistical analyses, as were those who missed more than one session. This eliminated six participants: 2 from Cohort IN, and 4 from Cohort NI.

Settings

A number of differences were found between schools in academic attainment as assessed by National Curriculum levels achieved at the end of primary school, in English (t = −3.52, df = 40.90, p < 0.001), Mathematics (t = −3.54, df = 51.75, p < 0.001) and Science (t = 3.69, df = 54.25, p < 0.001). In each case achievement was higher for schools in Cohort NI. Schools in Cohort NI were also found to have fewer children with special educational needs (SEN) sufficiently severe to warrant external agency involvement (t = 4.11, df = 58.93, p < 0.001) and fewer children receiving free school meals as an indicator of poverty (t = 2.77, df = 38.56, p < 0.01). Cohorts did not differ in the percentage of absences recorded by schools, but there were differences in school size, with schools in Cohort NI being larger (t = 4.08, df = 56.98, p < 0.001).

Procedure

Groups were led by one of three female trainee educational psychologists, and co-facilitated either a teacher or a support assistant. Co-facilitators provided support during the sessions and monitored participants’ progress (particularly when completing homework activities) during the week. They also rated each session’s fidelity to the manualized programme on a scale of 1–5. Mean fidelity of implementation scores were calculated for each group (n = 13) by averaging the scores given by co-facilitators across the six sessions (maximum score per session = 5). Scores across all groups were high (M = 4.76, SD = 0.23) and there were no significant differences between cohorts or facilitators.

The anger management programme, ‘Learning How to Deal with our Angry Feelings’ is a six-week, group work course for 7- to 11-year-olds based on the Southampton Anger Management Model (Faupel, Herrick, & Sharp, 1998). It is a targeted prevention programme, which aims to help children with anger-related difficulties recognize their angry feelings and develop strategies to deal with these appropriately. Each session lasts about 45-minutes. Sessions cover the following topics: Getting to know each other; What things make us angry?; Getting angry; Calming down—’thinking differently’; Calming down—’putting out the fuse’; Using our calming down ideas. In addition, following the model developed by Sharp and Herrick (2000), class teachers were provided with basic training on the intervention’s principles, particularly the ‘firework model’ of anger, and encouraged to use them in class. Parents and carers were also offered this information. 44 parents (62.9%) attended an initial meeting with the facilitators: 28 for Cohort IN, and 16 for Cohort NI.

Measures

The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997)

The SDQ is widely used and well-validated screening measure of adjustment and psychopathology in 4- to 16-year-old children. Psychometric evaluations of the instrument have shown satisfactory convergent, discriminant and convergent validity (Van Roy, Veenstra, & Clench-Aas, 2008). It has five subscales (of five items each, rated on a three-point scale): Pro-social Behavior, Conduct Problems, Hyperactivity, Emotional Symptoms, and Peer Problems. Subscale totals are the sum of the scores for the five items (0–10). The Total Difficulties score is obtained by summing the scores on four of the five subscales, excluding Pro-social Behavior. Internal consistency reliability for the total score in this study (Cronbach’s alpha = 0.79) was similar to that reported by Goodman (2001) for teacher-completed questionnaires (Cronbach’s alpha = 0.87).

The Anger Management Assessment (Southampton Psychology Service, 2003)

The Anger Management Assessment was designed to be used with the ‘Learning How to Deal with Our Angry Feelings’ programme. It assesses participant understanding of anger as an emotional state and their perceptions of their experience of anger. Seven of its nine items ask participants to rate various aspects of their experience of anger-related behavior (such as incidences of shouting, swearing and aggression, or how long it takes them to calm down) on a ten-point Likert scale. The scores on these seven items are summed to give an overall score which was found to have good internal consistency reliability (Cronbach alpha = 0.79). In addition, there are two open-ended items which ask participants to list changes in the body when they are angry, and strategies used to calm down. Answers to these questions were coded according to a list of acceptable responses, the score for each of these items consisting of the number of acceptable responses produced.

Results

Study hypotheses were tested using mixed (3 × 2) ANOVAs across time periods and cohorts. Testing of assumptions led to the use of the Huynh-Feldt correction in instances where the assumption of sphericity was violated. The results are presented in relation to the two key questions which the study was designed to address.

Can short-term, CBT-based anger management groups for pre-adolescents produce both immediate and sustained improvements in participant’s understanding of anger as an emotional state and their self-reported experience of anger?

A similar pattern of results was obtained on both of the ‘Understanding of Anger’ scores where there was a significant interaction between time and cohort. On knowledge of bodily sensations associated with anger there were significant main effects of time, F (2, 118) = 16.17, p < 0.001, partial eta² = 0.215 and cohort, F (1, 59) = 8.37, p < 0.005, partial eta² = 0.124, and a significant interaction between time and cohort, F (2, 118) = 10.44, p < 0.001, partial eta² = 0.150. Post-hoc t-tests supported the study hypotheses in that an increase in knowledge of bodily sensations associated with anger was observed for Cohort IN between Time 1 and Time 2 (t = −4.75, df = 32, p < 0.001), but for Cohort NI between Time 2 and Time 3 (t = −4.55, df = 29, p < 0.001). Additionally, changes noted in Cohort IN at Time 2 were maintained at Time 3: there was no significant decrease in scores (t = 0.86, df = 30, p = 0.40).

On knowledge of calming down strategies there was a significant main effect of time, F (2, 118) = 25.07, p < 0.001, partial eta² = 0.298, but not of cohort, F (1, 59) = 3.34, p = 0.07, partial eta² = 0.054. However, there was a significant interaction between time and cohort, F (2, 118) = 22.93, p < 0.001, partial eta² = 0.280. As for bodily sensations, post-hoc t-tests supported the hypothesized differential time patterns, showing an increase in knowledge of calming strategies for Cohort IN between Time 1 and Time 2 (t = −5.66, df = 32, p < 0.001), but for Cohort NI between Time 2 and Time 3 (t = −5.95, df = 29, p < 0.001). However, in this case, the decrease in the scores of Cohort IN between Time 2 and Time 3 was approaching significance (t = 1.98, df = 30, p = 0.06).

On the Perceived Anger total score there was no significant main effect of time, F (1.75, 103.34) = 0.73, p = 0.49, partial eta² = 0.012, or of cohort, F (1, 59) = 0.14, p = 0.71, partial eta² = 0.002. There was no significant interaction between time and cohort, F (1.75, 103.34) = 0.76, p = 0.46, partial eta² = 0.013. This suggests that there were no differences between the performances of two cohorts across the three time periods. Hence, even though children’s understanding of anger showed intervention-contingent improvement, the children's self-reports did not indicate any change in their experience of anger.

Can short-term, CBT-based anger management groups produce both immediate and sustained improvements in teacher-rated problem behaviors (including emotional symptoms, conduct problems, hyperactivity-inattention and peer problems) and pro-social skills?

Analysis of results on the Total Difficulties score indicated a significant main effect of time, F (1.81, 108.52) = 8.37, p < 0.001, partial eta² = 0.122, but not of cohort, F (1,60) = 0.011, p = 0.88, partial eta² = 0.000. However, the time main effect was qualified by a significant interaction between time and cohort, F (1.81, 108.52) = 6.83, p < 0.005, partial eta² = 0.102. Post-hoc t-tests indicated that the hypotheses (i) and (ii), relating to Cohort IN were not supported. However, there was support for hypothesis (iii), relating to Cohort NI. As predicted, there was no difference between scores at Time 1 and Time 2 (t = 0.59, df = 30, p = 0.56), but there was a significant decrease in the Total Difficulties score between Time 2 and Time 3 (t = −3.24, df = 29, p < 0.005).

To explore further the nature of these changes a doubly multivariate analysis was conducted to assess changes over time across cohorts on the four SDQ subscale scores that make up the Total Difficulties score (emotional, conduct, hyperactivity, peer problems). The sample sizes were equal across the groups, therefore the assumptions set by Leech, Barrett, and Morgan (2008) were considered to be met. Significant multivariate effects were found for the main effect of time, F (8, 53) = 3.06, p < 0.01, partial eta² = 0.316, but not of cohort, F (4, 57) = 0.07, p = 0.99, partial eta² = 0.005. This main effect of time was qualified by a significant interaction between time and cohort, F (8, 53) = 2.46, p < 0.05, partial eta² = 0.270.

For conduct and peer problems scores, follow-up ANOVAs revealed similar patterns to those obtained for the Total Difficulties score. Both showed a significant main effect for time, but not for cohort: conduct, F (2, 120) = 3.89, p < 0.05, partial eta² = 0.061; peer problems, F (2, 120) = 4.04, p < 0.05, partial eta² = 0.063. However, this was qualified by a significant interaction between time and cohort for both: conduct, F (2, 120) = 4.40, p < 0.05, partial eta² = 0.068; peer problems, F (2, 120) = 3.92, p < 0.05, partial eta² = 0.054. Post-hoc t-tests revealed no significant difference for Cohort IN at any point in time, on either measure. For Cohort NI, however, there were, as hypothesized, no significant differences between Time 1 and Time 2, but a significant difference between Time 2 and Time 3 on both measures: conduct, t = 3.64, df = 30, p < 0.001; peer problems, t = 3.64, df = 30, p < 0.001. This suggests a significant effect of the intervention for children in Cohort NI, but not for children in Cohort IN, on teacher rated conduct and peer problems.

The patterns of results obtained on the Emotional Symptoms and Hyperactivity sub-scales offered no support for the study hypotheses. On Emotional Symptoms there were no significant main effects for time, F (1.72, 103.31) = 2.35, p = 0.10, partial eta² = 0.038, or cohort, F (1,60) = 0.06, p = 0.80, partial eta² = 0.001, nor was there a significant interaction between time and cohort, F (1.72, 103.31) = 2.83, p = 0.07, partial eta² = 0.045. For Hyperactivity there was a significant main effect for time, but not for cohort: F (2,12) = 6.55, p < 0.005, partial eta² = 0.98 and there was no significant interaction effect: F (1, 120) = 1.60, p = 0.20, partial eta² = 0.026. Post-hoc tests revealed significant differences between cohort means only between Time 1 and Time 3 which suggests that the hyperactivity of both cohorts reduced between Time 1 and Time 3.

Finally, a mixed (3 x 2) ANOVA was conducted to assess whether there were differences between scores on the Pro-social scale of the SDQ across periods and cohorts. There was no significant main effect for time, F (2, 120) = 1.79, p = 0.17, partial eta² = 0.029, though there was a significant main effect for cohort, F (1,60) = 6.91, p < 0.05, partial eta² = 0.103. There was no significant interaction between time and cohort, F(2,120) = 1.16, p = 0.32, partial eta² = 0.019. Analyses of mean scores indicated that Cohort NI had higher pro-social scores than Cohort IN from the outset.

Discussion and implications

It was hypothesized that Cohort IN would show significant improvements during the first phase of the study relative to Cohort NI, and that this effect would be maintained at follow-up. This hypothesis was not supported by results on a self-report measure of experience of anger, or on teacher-rated measures of behavior and adjustment. However, measures of participants’ understanding of anger as an emotional state did change as hypothesized, showing significant improvement directly post-intervention, and maintenance at follow-up. Overall, these results suggest that although participants in Cohort IN were able to recall aspects of learning in the groups (such as calming down strategies and bodily responses to anger), this learning did not change either their own experience of anger, or the way in which their behavior was viewed by their teachers.

By contrast, the hypothesis relating to Cohort NI was largely supported. There were significant improvements in participant’s understanding of anger between Times 2 and 3, but not between Times 1 and 2. There was also support for the hypothesized pattern of changes on teacher-rated total difficulties, attributable to changes in conduct and peer problem scores. These results suggest that this group of participants were able to recall learning from the groups directly post-intervention, and to apply these to some aspects of their school life apparent to their teachers.

It should be noted, however, that in Cohort NI, children’s self-rating of anger did not change. It may seem intuitive that a child who is behaving better in class would also experience less anger. Yet it should be noted that the emphasis of the programme focuses not on the ability to repress or change emotions—anger can, it teaches, function as a survival mechanism—but rather to ‘recognise, understand, handle and appropriately express [one’s] own emotions’ (Faupel 2003, p. 3). In this sense, it does not aim to change the individual’s innate disposition towards anger––what might be termed ‘trait anger’ (Spielberger, 1988)—but rather to nurture the ability to regulate and express that emotion in a safe and appropriate manner. From this perspective, it is perhaps not surprising that the participants’ self-rating of anger did not change during the intervention period. Instead, it could be argued that there were changes in the way that this anger was managed, as rated by teachers. This finding is consistent with a number of other intervention studies, which have found that changes are much more likely to involve increases in self-regulation than decreases in experiences involving anger (Humphrey & Brooks, 2006; Robinson, Smith, & Miller, 2002).

Summary

In summary, the efficacy of the ‘Learning How to Deal with our Angry Feelings’ programme was mixed, differing according to cohort. As Cohorts NI and IN were closely matched pre-intervention, it is interesting to consider potential explanations for these differing outcomes, and the implications that this result might have for other similar programmes. Firstly, it is possible that there were qualitative differences between the interventions administered at the two phases. Facilitators were perhaps more confident when delivering the intervention for the second time, thus strengthening the therapeutic relationship with Cohort NI. However, this seems to be an unlikely explanation, given that the programme was strictly manualized, with co-facilitators rating fidelity of implementation as comparable for both cohorts. A second explanation is that the waiting period engendered anticipation for those in Cohort NI, who were thus more motivated to change when the intervention was eventually delivered. Again, however, this seems to be unlikely. There is no evidence for this pattern in the literature; in fact, several researchers note quite the opposite effect, whereby the scores of those in wait-list control conditions get worse while they are waiting for the intervention (Webster-Stratton, Reid, & Hammond, 2001).

A third explanation relates to the one significant difference on the outcome measures between the two cohorts pre-intervention: The pro-social scores on the SDQ, which were significantly higher for children in Cohort IN. Researchers disagree regarding the extent to which response to CBT for anger-related difficulties can be influenced by pre-existing severity of symptoms. Some researchers have found that children with fewer pre-existing socio-emotional difficulties improve most following intervention (Kazdin & Crowley, 1997; Kazdin & Wassell, 2000). Others, however, suggest that such interventions have more impact on children with greater levels of emotional and behavioral problems, and poorer social problem-solving skills (Hemphill & Littlefield, 2001; Lochman, Lampron, Burch, & Curry, 1985). It is possible that this particular intervention might have been of more benefit to children with fewer pre-existing social skills, particularly given the socially-oriented, group nature of the programme and the emphasis of the programme on social skills acquisition. While the intervention did not bring about changes in pro-social skills for either cohort, it is perhaps of interest that Cohort NI experienced significantly fewer peer problems post-intervention, as measured by teacher report. It is possible that this group of children benefited more from social instruction, as they were in greater need of support in this area.

The fourth explanation relates to differences not at an individual, but at a systemic level. It was noted that there were a number of statistically significant differences between schools in Cohort IN and NI, in terms of academic attainment levels, special educational needs and socio-economic disadvantage. On all measures, schools in Cohort IN showed greater levels of need. The possibility that differences at a school level may have affected the efficacy of the intervention seems plausible for a number of reasons. It has been shown that higher levels of social deprivation within an area affect treatment gains from cognitive-behavioral interventions. Kazdin and Wassell (2000), for instance, found that greater social disadvantage resulted in less therapeutic change.

Although individual students in the present study were matched across cohorts on levels of free-school meals (as an indicator of poverty), research has shown that school poverty level predicts aggression independent of the child’s own level of poverty (Kellam, Xiange, Mersica, Brown, & Ialongo, 1998). Children in advantaged schools (those with lower levels of social deprivation and higher achievement test scores) fare better than comparable children in less advantaged schools (Barth, Dunlap, Dane, Lochman, & Wells, 2004; Rutter, 1983). Research suggests that the number of children with behavioral or academic difficulties in a classroom can increase the amount of aggressive behavior exhibited by individual children, and, conversely, that changes in classroom or school environment can bring about changes in student behavior (Barth et al., 2004.). It is a limitation of this study that no information was collected on teachers’ use in class of the training provided on the principles of the intervention. While it might be anticipated that teachers in schools experiencing greater pressures in terms of academic results and social problems might have less capacity to respond to such training, this speculation would need to be tested by future research.

There are a number of other considerations for future research highlighted by this study. Some apply specifically to the way the study was designed: Matching participants rather than schools, for example. To overcome this, it would be desirable for future research to match both participants and schools, or to identify sufficient participants to randomly allocate an intervention and comparison group within each school. Others relate more generally to difficulties with carrying out a valid assessment of change, particularly when evaluating a group which targets anger as its primary variable. There is some ambiguity what it means to ‘manage anger’, and how this might be measured. Researchers in the field of anger management for children and young people have a number of different ways of measuring intervention effectiveness, including changes in anger expression, behavior, aggression, social problem solving, self-control and, more rarely, affective constructs such as self-concept and depression (for a review, see Cole, 2008). The most reliable studies offer a measure of cognitive as well as behavioral change, and provide data from a number of different sources (self, parent, teacher, or behavior data). Whilst this study made some attempt to measure cognitive change using the Anger Management Assessment, this in fact provided data which was largely behavioral in nature (instances of different behaviors and periods of time for calming down). Data was provided from self- and teacher-report, but there was no measure of behavior across contexts (with peers or parents). Future research may consider triangulating the sources of data (using parent or peer as well as teacher and pupil data, or observational approaches as well as questionnaires, for instance) and using a standardized measure of participants’ experiences of anger (such as the Children’s Inventory of Anger, Nelson, & Finch, 2000).

Additionally, this research highlighted a number of practical considerations for providers of psychological services for children with anger-related difficulties. It raises the issue of how children should be selected for school-based group interventions. In contrast to the clinic setting, where therapists might have large cohorts of children who can be carefully selected for appropriate groups, the school environment relies on ‘opportunity samples’ of children who might be quite different in their needs. Nonetheless, this current research suggests that schools should give careful consideration when planning a CBT based anger management intervention, as to which kind of children might benefit most from this approach. It suggests that group-based CBT may not be equally effective for all, and that those with fewer pre-existing social skills may improve most. This has implications for how such groups are used and how resources are prioritized within schools. In the current study, schools identified the participants for the group. It may be that the school’s psychologist could support the school to choose participants, screening pre-existing skills of possible participants to see who may benefit from the group and who might be more appropriate accessing alternative interventions.

Practical implications

Practical implications can also be drawn from the tentative finding that children varied in their response to the intervention based on the school they attended, with children in schools with lower levels of socio-economic disadvantage, higher academic attainment and fewer children with SEN, responding better. If, as research suggests, children from certain environments are more susceptible to anger-related difficulties, it is unreasonable to expect the child to change if the system remains the same. As Faupel (2006, p. 174) writes, ‘belongingness … is a matter of systemic issues rather than one of personal skills and competences’. This study highlights a particular need, in evaluating school-based interventions, to consider characteristics of the context in which change is sought (i.e. the school), as well as characteristics of the children selected for targeted interventions. When planning a school-based, CBT intervention, consideration should thus be given to whether teachers and support staff have the capacity to take on board the theories and concepts which underpin it (in this case, the firework model of anger), and reinforce these within the classroom. In addition to this, there might be a role for practitioners introducing whole-school interventions, running alongside smaller, more targeted intervention groups, which address emotional well-being across the entire school community. Examples of these include the SEAL (Social and Emotional Aspects of Learning) programme in the UK (DfES, 2005) and the PATHS (Promoting Alternative Thinking Strategies) curriculum in the US (Kusche & Greenberg, 1994) and beyond (Joha, Luit, & Vermeer, 1999). From this perspective, it is interesting to note that the programme evaluated in this current research was originally designed to operate as part of a broader set of interventions, which included a more general curricular emphasis on emotional literacy (Sharp & Herrick, 2000).

A related issue considers the role played by parents and peers in supporting and reinforcing the cognitive-behavioral approach. There is a suggestion in the wider literature that a cognitive-behavioral approach in isolation may be less effective for children with anger-related difficulties than a multi-modal approach. As a result, some programmes suggest a peer and/or parent training component in conjunction with individual CBT (Landau, Milich, & Diener, 1998; Webster-Stratton et al., 2001). This study made some attempt to engage teachers and parents by inviting them to information sessions. Future projects could valuably investigate extending the teacher and parent training components, or adding a peer training component, as a means of addressing contextual issues in seeking to enhance the effects of individually-focused, school-based intervention programmes for pre-adolescents.

Footnotes

Funding

Funding for this project was provided by Kent County Council, UK.

Author biographies

Rachel Cole is an Educational Psychologist in Kent, UK, and an Honorary Research Assistant at University College London, UK. Her recent interests include cognitive-behavioural therapy, working memory, attachment theory, dyscalculia, and crisis support. Address: Kent Educational Psychology Service, 1–4 New Road, Gravesend, Kent, DA11 0AT, UK. Email: Rachel.cole@kent.gov.uk

Susanne Treadwell is an Educational Psychologist in Camden Educational Psychology and Youth Offending Services, London, UK. She previously worked as a teacher and a researcher at the Institute of Psychiatry, King’s College London. Her interests include psychotherapeutic approaches, resiliency factors, attachment relationships, and social and emotional development in adolescence. Address: Educational Psychology Team (Camden Council), Crowndale Centre, 218 Eversholt Street, London, NW1 1BD, UK. Email: susanne.treadwell@camden.gov.uk

Sima Dosani is an Educational Psychologist in Hertfordshire, UK. Her recent interests include cognitive-behavioural therapy, challenging behaviour difficulties, emotional and social difficulties and literacy difficulties. Address: Hertfordshire Multi-Agency and Psychology Service, Brindley Way, Hemel Hempstead, Hertfordshire, HP3 9BF, UK. Email: sima.dosani@hertscc.gov.uk

Norah Frederickson is Professor of Educational Psychology and Co-director of the Initial Professional Training Programme in Educational Psychology at University College London, UK. She served on the Board of Directors of the British Psychological Society (2000–2003). She is registered as an Educational Psychologist with the UK statutory registration body, the Health Professions Council. Her current research interests include social development and well-being in children and the promotion of inclusion and belonging in schools. Address: Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1E 0AP, UK. Email: n.frederickson@ucl.ac.uk

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