Community Temper Taming Project

ABSTRACT

Objective: To examine the effectiveness of a group cognitive-behavioural therapy (CBT) program in reducing anger and aggressive behaviour in aggressive children.

Method: There were 68 children, aged 7 to 13 years, and their parents who participated in the study. Twelve groups were run at an outpatient children’s mental health centre. The children were referred to the groups by their clinician for assistance in reducing their aggressive behaviour. Quantitative information on the effectiveness of the group was obtained from children and their parents who completed questionnaires before the first session and after the last session. The children completed the Children’s Inventory of Anger (CIA) and a group satisfaction measure and the parents completed the Children’s Hostility Inventory (CHI). T-tests and analyses of covariance were used to test for differences at post-treatment.

Results: Results were available for 56 children. At post-treatment, children reported that the intensity of their anger had decreased (e.g., CIA t(41)=4.39, p<.0001) and parents indicated a reduction in frequency of aggression (e.g., CHI-Aggression, t(44)=2.82, p<.01) and hostility (e.g., CHI-Hostility, t(44)=4.93, p<.0001) in their children. Children also reported that they found the group helpful in reducing anger.

Conclusions: The group program appeared to reduce children’s anger and aggression. However, the results are preliminary and further controlled evaluation is required.

Clinical Implications:

• If further validation confirms the effectiveness of this program in the reduction of anger and aggressive behaviour, then the program will be available as an easy-to-implement, time-limited intervention.

• A randomized control trial with longer-term follow-up is needed to replicate findings to provide further evidence for the effectiveness of the program.
• Further evidence for the clinical significance of the gains made by the children in the group would be provided by similar results on observational measures and reports from others, such as teachers and peers, as well as overall indices of the children’s functioning.

INTRODUCTION
Behavioural problems are the most common presenting problems to children’s mental health centres (1). When 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 are developed that decrease anger and aggression early in childhood.

Programs for reducing anger and aggression are typically either community-based (e.g., 5) or clinic based (e.g., 6). Most children in clinic-based programs demonstrate significant levels of anger and aggression and, if left untreated, will continue to have significant problems functioning in adolescence. Clinic-based programs can focus mainly on the child (7), 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 that they are time-intensive for participants and require intensive training for the facilitators of the intervention. This study conducts a pilot investigation of a short-term, cognitive-behavioural therapy (CBT) group program for anger and aggression 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 a variety of mental health problems. Children with Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Major Depressive Disorder (MDD), and a variety of 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 usually receive frequent negative feedback from parents. The negative feedback aggressive children receive from parents, peers, and authority often maintains their aggressive behaviour (12).

BACKGROUND
Anger and aggression are interrelated constructs and may occur alone or simultaneously. In many instances, anger is a precursor to aggression (13). Anger is an emotion and can range in intensity from annoyance to rage (14). Aggression is a behaviour and can be verbal or physical. Hostility is another aspect of aggression and 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 become hurt and then quickly angry, for instance, if he believes that a friend has deliberately ignored him (versus his friend did not see him) on the schoolyard. Compared with non-aggressive children, aggressive children are more likely to interpret ambiguous actions of others as hostile (17).

Strategies to help children recognize when they are upset (i.e., become aware of experiential and physiological aspects of emotion), become aware of common triggers for their upset, and recognize the biases in their thinking should be useful in helping them 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, that target specific skills appear to be more effective than eclectic programs in reducing anger and aggression (18).

CBT has been shown to be an effective therapeutic treatment for angry and aggressive children presenting to clinics (7,10). Kazdin’s (7) Problem-Solving Skills Training (PSST) program is an adapted CBT model that has significant research supporting its effectiveness in reducing anger and aggression. It emphasizes problem-solving 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 (i.e., 25 weekly sessions).

This study involves a nonrandomized evaluation of the Temper Taming Program (19). The Temper Taming Program is an 8-week group CBT program which 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 co-exist with, anger and aggressive behaviour. It is hypothesized that the intensity of anger and frequency of aggressive behaviours in the children will decrease by the end of the program. More specifically, there should be a reduction in anger reported on the Children’s Inventory of Anger (CIA) and aggression reported on the Children’s Hostility Inventory (CHI) at post-treatment compared to pre-treatment.

METHOD

Participants: The participants were 68 children who participated in 12 groups. There were 56 boys and 12 girls. The children ranged in age from 7 to 13 years old (average age = 9.6 years old, SD = 1.55) and were all patients at an outpatient children’s mental health centre. The children were referred to the groups for their aggressive behaviour by the clinician managing their assessment and treatment. Most had been diagnosed with one or more externalizing or internalizing disorders (e.g., Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Anxiety Disorder, or Conduct Disorder) during their initial assessment with the centre’s psychiatrist.

Group Format: Children attended 8-weekly one hour sessions held during the day or immediately after school. Parents attended 3 parent group sessions in the evening coinciding with weeks 1, 4, and 8 of the children’s program (for 2 groups, parents were required to attend all 3 parent sessions prior to the beginning of the children’s sessions). All groups were facilitated by 2 co-leaders. The leaders were psychologists, social workers, child and youth workers, family therapists, psychiatric residents, and psychology interns. All group leaders participated in a 1-day training program prior to leading the groups and followed a manual detailing each group session when running the groups.

Program Description : The group's goal is to reduce "temper", including anger and aggression, and to help children recognize that there are many feelings, including anger, that can occur immediately prior to losing one's temper. The first component of the program identifies these feelings and the corresponding physiology, cognitions, and behaviour. The second component of the program empowers children by helping them recognize that they have control over their temper. The children are taught to recognize when they are about to lose their temper and are then encouraged to make a choice about their subsequent action. By teaching the children to think through the consequences of their actions, the children learn to make alternative choices to losing their temper. The children are also taught how to problem-solve the situations that give rise to the feelings and cognitions that trigger their temper so that they can learn to resolve the situation without losing their temper. Parents attend 3 parent group sessions to learn the same strategies the children are learning in order to support their children when they practice their new skills.

Procedure: Twelve groups were run over 2_ years. The children and their parents were given questionnaires to complete immediately before the first session and immediately after the final session (for 1 group, the parent questionnaires were given out at a follow-up meeting with the case manager and completed within 4 weeks of the end of the group). The children completed the Children’s Inventory of Anger (CIA) (13) and the parents completed the Children’s Hostility Inventory (CHI) (13). The children also completed a group satisfaction measure immediately after the final session (6 groups completed a group satisfaction questionnaire).

Of the 68 children enrolled, 63 completed the groups. Pre-data were missing for 2 children and post-data were missing for 4 children because of non-returned forms, lost forms or administrative error. One child was missing parent pre- and child post-data because of failure to return forms. Therefore, data on 56 children were available for analysis. Not all children had both the parent- and child-report measures administered and/or completed.

Measures: Children’s Inventory of Anger (CIA) (13). This 21-item self-report measure was completed by the children. The children were asked to rate how angry they become in different situations on a 4-point Likert scale ranging from 1 = “I don’t care. It doesn’t bother me” to 4 = “I can’t stand that! I’m furious”. The test-retest reliability is r=0.63 to 0.90 and internal consistency is good (alpha = 0.96) (13). Validity for the measure is supported in its correlation with peer ratings of anger (20).

Children’s Hostility Inventory (CHI) (15). This 34-item questionnaire was completed by the parents. Each item describes an aggressive behaviour and the parents responded “True” or “False” to indicate whether the children demonstrated the behaviour. There are two subscales: aggression (17 items) and hostility (14 items). The internal consistency of the entire scale is good (alpha = .82). The aggression subscale assesses overt forms of aggression and the hostility subscale assesses covert, attitudinal forms of aggression. Validity for the two subscales is supported by their correlation with the Externalizing scale of the Child Behaviour Checklist (21), clinician ratings of antisocial behaviour and teacher ratings of aggressive behaviour (15).

Group Satisfaction Measure. A questionnaire was developed for the study to obtain information on the children’s overall impressions of their experiences upon completion of the group program. The children provided written comments and indicated how helpful the group was on a 10-point Likert scale ranging from 1 = “not at all helpful” to 10 = “very helpful”.

Results: The age range and gender of the 56 children included in the analysis is presented by group in Table 1. Attendance information was available for 53 of these children: 76% of the children attended all of the 8 sessions, and 100% attended 5 or more; 94% of the parents attended at least 2 of the 3 parent sessions.

Correlations were calculated between the CIA pre scores and the two CHI subscale pre scores - Aggression and Hostility. CIA pre scores did not correlate with the CHI Aggression pre score (r=.08, p=.59), suggesting that the children’s ratings of their anger in response to specific, anger-provoking situations is a distinct construct from their parents’ ratings of overt aggression. However, CIA pre scores did correlate with the CHI Hostility pre score (r=.31,p=.04), suggesting that the children’s ratings of their anger is a similar construct to their parents’ ratings of hostility, or, covert attitudes such as resentment and suspicion. There was also a significant correlation between the CHI Aggression pre score and the CHI Hostility pre score (r=.39,p=.003), confirming that the two scales measure a related “aggression” construct.

Mean scores on outcome measures are presented in Table 2. One-tailed t-tests were conducted to evaluate the hypothesized improvements on the 3 scales measuring anger, aggression, and hostility. Children reported that their level of anger (CIA) significantly decreased by the end of the group, t(41)=4.39, p<.0001. The effect size for this change is .69. In addition, the parents reported that the frequency of their children’s overt aggressive behaviours (CHI-Aggression) and hostility (CHI-Hostility) significantly decreased by the end of the group, t(44)=2.82, p<.01 and t(44)=4.93,p<.0001, respectively. The effect sizes for these two changes are .39 and .56, respectively.

Age and gender were not found to be associated with the improvement on anger, overt aggression, or hostility at the end of the group when analyses of covariance were conducted.

On the group satisfaction measure, over four-fifths of the children reported that the group helped them. Satisfaction was defined as a score of 6 or more on the 10-point Likert scale and satisfaction ratings were obtained from 33 of the children. Therefore, the children’s subjective ratings were in line with the results on the measures of anger, aggression and hostility.

Discussion: The 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. Children’s subjective evaluation of the group also indicated that the group was helpful.

Retention and attendance rates were also good. Only 7% of the children dropped out of the group, and attendance was strong with over three-quarters of the children attending all 8 of the group sessions and all of the children attending more than half of the sessions. The strong retention and attendance rates are encouraging given that 40-60% of children in outpatient settings end treatment prematurely (22) and the most difficult children to treat are often those who drop out of treatment (23). Based on the results of the group satisfaction measure, one explanation for the good retention and attendance rates is that the children perceived the group to be helpful. The skills being taught were simple and generalizeable to the situations they encountered that typically triggered anger and aggression.

The group format may have also increased retention and attendance rates as the children were able to develop some positive relationships with the children in the group under the close monitoring of the group co-leaders. Given that there is often a requirement for children to socialize in groups at school, in sports and in community programs, it may be that the Temper Taming group provided a positive experience for the children to help with real-life peer group situations in contrast to the experiences they have in other groups they belong to.

Almost all parents attended 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, versus after school or during the day for the children’s group. It is possible that there were barriers to attendance in the evening such as child care responsibilities. Barriers to attendance may be reduced further by offering the program closer to the parent’s home at their children’s school and 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. It is possible that as the children continue to practice the skills learned in the group once the group is over, they would continue to reduce their anger and aggression over time. A booster session a few months after the end of the group may remind the children to regularly use the 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, treatment motivation, age, and gender. For instance, the children and parents who participated in this study may have benefited because they were motivated for change (24). This is likely not the case for some children with behavioural problems. The parents and children in this sample represented those who had come to a child psychiatry outpatient clinic for assistance and had followed through on treatment recommendations by their clinician. Unfortunately, some parents and their children with behavioural problems are not motivated to obtain assistance.

Further evidence for the clinical significance of these findings requires further investigation and would be provided by finding similar results on measures assessing 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 in assessing clinical significance.

Conclusions: The 8, one-hour sessions of the CBT Temper Taming group program appear to reduce children’s anger and aggression. The advantages of the Temper Taming Program over other programs targeting anger and aggressive behaviour is that it is short-term, thus more likely to ensure treatment adherence, is cost-effective because it is a group and is only 8 weeks, and does not require extensive training to run.

References:
1. Offord, DR, Lipman, EL. Emotional and behavioral 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 (Eds). Peer rejection in childhood. NY: Cambridge University Press. 1990.
3. Cairns, RB, Cairns, BD. Lifelines and risks: Pathways of youth in our time. NY: Harvester, Wheatsheaf. 1994.
4. Loeber, R. Antisocial behaviour more enduring than changeable? J Am Acad Child Adolesc Psychiatry. 1991;30:393-399.
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;25:179-188.
6. Grizenko, N. Outcome of multimodal day treatment for children with problems: A five year follow-up. J Am Acad Child Adolesc Psychiatry. 1997;36:987-997.
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;57:522-535.
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;57:550-553.
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;60:733-747.
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: author. 1994.
12. Patterson, GR. Coercive Family Processes. Eugene, OR: Castalia. 1982.
13. Finch, AJ, Saylor, CF, Nelson III, WM. Assessment of anger in children. In Prinz, RJ. (Ed). Advances in Behavioural Assessment of Children and Families. Greenwich: JAI Press.1987;3:235-265.
14. Nelson III, WM, Hart, KJ, Finch Jr., AJ. Anger in children: A cognitive behavioral view of the assessment-therapy connection. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 1993;11:135-150.
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;16:320-328.
16. Beck, AT, Rush, AJ, Shaw, BF, Emery, G. Cognitive therapy of depression. NY: 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 proplems in primary school children: A preliminary evaluation of a modified cognitive-behavioural approach. Aust NZ J Psychiatry. 1998;32:379-386.
19. Mills, B, Evans, P. Temper Taming Program Manual. Hamilton: Chedoke Child and Family Centre. 1999.
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. Burlington, VT. University Associates in Psychiatry. 1983.
22. Wierzbicki, M, Pekarik, G. A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice. 1993;24:190-195.
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. Prochaska, JO, Velicer, WR, Rossi, JS, Goldstein, MG, Marcus, BH, Rakowski, W, Fiore, C, Harlow, LL, Redding CA, Rosenbloom D, et al. Stages of change and decisional balance for 12 problem behaviours. Health Psychol. 1994;13:39-46.

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