CRD summary

This review evaluated the effectiveness of cognitive-behavioural therapy (CBT) for anger in children and adolescents. The authors concluded that CBT is effective. There are insufficient details of the included studies to allow an independent judgement of the reliability of the conclusions.

Authors' objectives

To evaluate the effectiveness of cognitive-behavioural therapy (CBT) for anger-related problems in children and adolescents.

Searching

PsycLIT, MEDLINE, and Dissertation Abstracts International were searched for studies reported in English; the search terms used were reported. The reference lists of individual outcome articles and previous meta-analyses were manually checked, and the authors of one key systematic review in the field were contacted.

Study selection

Assessment of study quality

The studies were assessed and coded with regards to random assignment, blinding of the raters and treatment integrity. The first author coded the included studies. A second reviewer then independently coded a random sample of 25% of the papers.

Data extraction

The first author coded the studies. A second rater then independently coded a random sample of 25%. Any disagreements were resolved by discussion. Characteristics of the participants, study design, treatments, therapists and outcome measures were coded. Data were extracted to calculate effect size for each outcome in each study. If a study compared more than one treatment with control, each comparison was treated as a separate study.

Methods of synthesis

Results of the review

Twenty-one published studies and 19 unpublished studies were included; the total number of participants was 1,953. These studies provided 51 treatment versus control comparisons.

The overall pooled analysis (mean d=0.67) included 173 effect sizes, generated from 40 studies of all relevant measures and comparisons. Since the value was in the medium range it indicated that the average child receiving CBT would be in the lower quartile of the nontreated group. However, there was evidence of statistical heterogeneity (Q=250.42, d.f.=172, P<0.0001). The effect sizes by domain of measurement, source of information and treatment type varied from 0.63 to 0.73, -0.07 to 0.69 and 0.36 to 0.79, respectively; skills training and multimodal interventions were the most effective treatment types. It was also found that feedback, modelling and homework assignments were all statistically positively related to the overall effect size (Spearman rank-order correlation, rho=0.55, P<0.001; rho=0.46, P<0.001; rho=0.31, P<0.05, respectively).

Results of the tests of inter-observer agreement levels ranged from 0.87 to 0.51 for treatment type, problem severity and treatment integrity.

Using a 'small effect' value of 0.20 in the fail-safe N calculations, the authors anticipated that an extra 117 studies with small effect size would be required to reduce the overall d-value to 0.20.

There was no significant difference in the overall effect size between published and unpublished studies (d=0.64 and d=0.70, respectively, P<0.59).

Randomisation, rater blinding and treatment integrity were found not to be significantly related to the magnitude of the effect size.

Authors' conclusions

CBT is an effective treatment for anger-related problems in youth. Its effects are consistent with the effects of psychotherapy with children in general.

CRD commentary

The review question was clearly defined. Relevant electronic databases and other sources were searched for published and unpublished studies. The review might be subject to language bias because only studies reported in English were eligible for inclusion.

Samples of the data were extracted twice in order to reduce reviewer biases; inter-rater agreement ranged from high to fair. Details of the participants, intervention, outcomes measured and results for each individual study were not shown; it is therefore difficult to draw conclusions about the appropriateness of the authors' decision to pool the data, or the reliability of the pooled estimates. Since the effect size was not measured in the units of any of the outcomes measured in the included studies, the interpretation of the authors' conclusion regarding effectiveness is not straightforward.

Implications of the review for practice and research

Practice: The authors stated that it appeared that treatments that teach actual behaviours or include problem-solving are more effective than treatments that modify internal constructs or affective education treatments, such as relaxation. The use of homework was significantly and positively related to therapy outcomes, while the use of CBT seemed most beneficial for children with moderate anger-related problems rather than those with a history of violent behaviour.

Research: The authors stated that with regard to CBT, a meta-analysis could be used to investigate the mechanisms of change, moderators of outcomes, and exportability from clinical research to practice.

Bibliographic details

Sukhodolsky D G, Kassinove H, Gorman B S. Cognitive-behavioral therapy for anger in children and adolescents: a meta-analysis. Aggression and Violent Behavior 2004; 9(3): 247-269.

Indexing Status

Subject indexing assigned by CRD

MeSH

Adolescent; Aggression; Child; Child Behavior Disorders /therapy; Cognitive Therapy

AccessionNumber

12004009686

Database entry date

31/08/2005

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.