Cognitive Behavioural Therapy Treatment for Child Anger Management
Abstract
Cognitive Behavioral Therapy (CBT), commonly used to treat various mental health problems, focuses on the relationship between thoughts, emotions and behavior of the patient to address and alter the dysfunctional behavior. CBT is a time-restricted, present-focused technique which educates clients about cognitive and behavioral proficiencies to pursue their interpersonal and intrapersonal lives more adaptively. CBT is also used in children to encourage self-control and address behavioral issues. This paper reports a case study of a nine- year old patient. Using CBT, problematic anger presentation after parental divorce is regulated. The efficiency of CBT is evaluated for this case.
Keywords: Anger management, anger management in children, CBT, Mindfulness
Introduction
Anger is defined as an affective state that could be problematic to the individual and so leads to application for therapeutic aid. Anger, fear and sadness tend to be common feelings and most of the time, are functional for the individual. Yet, these feelings, if unchecked, have the tendency to cause aggression, avoidance and withdrawal which could cause irritation to the person concerned as well as others (Howells & Day, 2003).
The lack of proper management of emotional skills can result in the expression of anger in a dysfunctional and destructive way. Hence, anger management is imperative for children who cannot comprehend and/or regulate their anger. The uncontrolled expression of anger can be altered through the use of behavioral methods (Flanagan, Allen, & Henry, 2009). It has been suggested that child depression and expressing anger aggressively tend to be associated. Children who are depressed were found to experience impairments in expressing their anger using a regulated style when compared with children who are not depressed. However, Flanagan et al. (2009) concluded that the type of anger expression could be more associated with the characteristic of depression in children. On the other hand, it has been posited that no specific differences can be determined between depressed and non-depressed children in terms of suppressing anger or expressing anger aggressively (Kashani, Dahlmeier, Borduin, Soltys, & Reid, 1995). It is clear that there are conflicting reports on the nature of anger expression and depression among children. This supports the need for further investigation into this area in order to provide practitioners with more insights into this extremely important area of children’s mental health.
CBT intervention has been successfully used in children to foster self-control and address behavioural issues (Wesson, 1993). CBT is a time-restricted, present-focused technique which educates clients by leveraging on cognitive and behavioural proficiencies to pursue their interpersonal and intrapersonal lives more adaptively (Mennin, Heimberg, Turk, & Fresco, 2006).
As another evidence-based psychotherapeutic intervention, Mindfulness-based cognitive therapy (MCBT) combines various parts of cognitive behavioural therapy mainly recommended for alleviating depressive symptoms. MBCT is based on the opinion that meditation encourages people to efficiently expand and regulate attention in order to efficiently regulate and intervene various psychological symptoms including emotional reactions to stress, anxiety and depression. The authors stated that, among children and adolescents, several researches showed that mindfulness-based interventions successfully alleviated the emotional responses that is related to the psychiatric difficulties (Sibinga, Copeland-Linder, Webb, Shields, & Perry-Parrish, 2016). MBCT involves aspects from CBT, for instance it includes activities that reflect the way individual’s thoughts, emotions and behaviour are interrelated. It involves teaching mindfulness skills and CBT elements so that the clients would have skills to recognize the automatic activation of usual dysfunctional cognitive processes and teach how to deal with them (van der Velden et al., 2015). Likewise, it was proposed that Mindfulness-based approaches tend to enhance psychological symptoms, promote emotion regulation, improve attention as well as improve the ability to focus and decrease dysfunctional coping and rumination. Thus, it could be said that, these advances could be related with improvements in calmness, relationships and decreased stress and thus reduces negative psychological symptoms (Sibinga, Copeland-Linder, Webb, Shields, & Perry-Parrish, 2016).
Case Presentation
The client in this case study was a nine-year old male from the city of Guzelyurt in Cyprus, whose parents sought help from a private psychotherapy clinic to deal with their child’s anger management issues. Both the client and the parents reported that following the divorce of the parents, the child, a boy, started to experience impairments in regulating his anger. The client reported that his relationship with friends and family had started to deteriorate as he has been having a hard time managing his anger and feeling regretful after such episodes. The client also reported that he wanted to have healthier relationships which led him to seek help to redress the issue. The client’s parents reported that their son had frequently been throwing tantrums both at home and school. At the same time, the client reported that he had been experiencing a low mood after the divorce of his parents.
CBT methods were applied in the present case to switch the client’s dysfunctional thinking patterns to functional ones. The intervention was carried out with the collaboration of the researcher’s supervisor and peer supervision.
The client and his parents attended six 50-minute sessions throughout six-week period from April to July 2019. Each session began with the client and in the final fifteen minutes, the session was completed with the participation of the client’s parents. The sessions were initiated and finalized by evaluating the mood of the client who was asked to rate on a scale of 10 how comfortable he was. Additionally, at the end of each session, the progress of the client was assessed by discussing how he was dealing with his anger in social contexts such as school and home.
In the initial session, which lasted for an hour, the client and the parents were informed about the ethical issues and confidentiality limits. Also, the therapy goals were determined with the collaboration of the client with a pictured therapy goal activity which was applicable to the developmental period of the client. As revealed previously, problematic anger expression and depression is related (Kashani et al., 1995). Hence, in this study, the possible development of child depression after parental divorce was evaluated. To assess the extent of the problematic anger presentation as related to child depression, the Children's Depression Inventory (CDI), a widely applied measure of children’s depressive symptoms, was applied (Reynolds, Wilson, Austin, & Hooper, 2012). It was found that the client’s symptoms were not adequate to meet the diagnosis criteria for depression.
Following the evaluation of the client’s emotions and behaviors, the therapist described the CBT method via the help of the CBT Children’s booklet that illustrates the relationship between thoughts, emotions and behavior with examples. Additionally, the CBT Children’s booklet includes a pictured ABC model with an example. The ABC model aids the therapist to propose an alternative perspective to the client regarding the origin of their disorder (David, Matu, Pintea, Cotet, & Nagy, 2014). Moreover, as employed in Bekirogullari and Olkanli (2019), the ABC model can be used by therapists to illustrate the relationship between the incident, thoughts and emotions. The therapist employed the pictured ABC model in order to understand the automatic thoughts of the client regarding the antecedent situation that leads to problematic anger expression.
In the first three sessions, the client was trained on accessing his automatic thoughts according to his emotions including understanding physical reactions to anger. Psycho-education was administered to the client and the parents in order to exemplify the basis of anger and the dimensions of pathology (Donker, Griffiths, Cuijpers, & Christensen, 2009). Montoya, Colom, and Ferrin (2011) clarified psychoeducation as an innovative intervention that involves information regarding the disorder and its treatment, skills advancement, and client acceptance. At the same time, the following paradigm was found to be well-developed evidence- based treatment for some serious adult psychiatric disorders.
In order for the client to manage his feelings in a more functional way, mindfulness was introduced and practiced with the patient. The patient was assigned homework to practice the newly introduced mindfulness methods. Psycho-education was also administered to the parents to facilitate the behavior modification methods required to teach the client the consequences of his behavior, to eliminate his dysfunctional behavior at home. On top of that, the pictured ABC model was believed to trigger in the client alternative thoughts and functional reactions to anger (David et al., 2014).
In the final session, progress evaluation was implemented with the parents and the client and it was reported that the tantrums had decreased to a certain extent. The client reported that the mindfulness methods worked giving him a space to think before reacting. It was observed that the client had acquired alternative views to the situation enabling him to regulate his emotions and behavior to a certain extent.
Previously learnt coping skills were revised with the client and the parents were reminded to apply behavior modification methods to assure the permanent change of the unwanted behavior.
Discussion
Anger seems to be increasingly affecting the normal life functioning among children. Increased anger and hostility are both related with health issues, while, at the same time, giving rise to bullying and disrupted teen relationships (Deffenbacher, Oetting, & DiGiuseppe, 2002).
Almost two decades ago, Howells and Day (2003) posited the efficacy of anger management techniques as implemented in CBT. This was followed by more research claiming CBT provides the possibility of learning self-control methods for anger management (Singh et al., 2008). Hutchinson, Willner, Rose, Burke, and Bastick (2016) found CBT interventions to be competent in reducing dysfunctional expression of anger, while Bekirogullari and Korusan (2019) proposed CBT as an efficient method to deal with various psychiatric issues.
Thus, there is sufficient research to underscore the use of CBT combined with mindfulness methods as an efficacious treatment for dysfunctional behaviours (Cayoun, 2004).
When integrated with CBT, mindfulness-based intervention methods also teach clients a coping method focused on the antecedent to aggressive reactions (Bekirogullari & Korusan, 2019).
In this case study, within the fifty-minute sessions, taking place within a period of six weeks, the therapist used CBT to focus on highlighting the relationship between thoughts, emotions and behavior while employing the ABC model to show and evaluate the thoughts of the client and how these thoughts led to problematic anger presentation. Both these techniques were successful in reducing the dysfunctional behavior of the client.
The use of CBT and mindfulness method integration is recommended as a future application as it can teach more efficient coping skills to children with anger presentation due to the distorted thinking patterns (Cayoun, 2004).
Conclusion
To conclude, we recommend that CBT be employed as an efficient intervention method for anger management with children. This study shows that CBT combined with mindfulness techniques are successfully in helping children to think about and amend dysfunctional behaviours.
It should be noted here that these techniques should only be implemented by trained CBT practitioners. To obtain the best results with children, parents should also be included in the therapy process as in case of our client. With the cooperation of the parents, the client showed a significant alleviation in managing anger in his daily life.
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