Indian Journal of Psychiatric Nursing

SYSTEMATIC REVIEW
Year
: 2020  |  Volume : 17  |  Issue : 1  |  Page : 51--56

Anger management in adolescents: A systematic review


Shamala Anjanappa1, Radhakrishnan Govindan1, Manjula Munivenkatappa2,  
1 Department of Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Correspondence Address:
Mrs. Shamala Anjanappa
Department of Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India

Abstract

Children and adolescents lack adequate skills to recognize and cope with the feelings of anger, which is often displayed in the school setting in the form of disruptive behaviors. Training adolescents with anger management skills reduces the negative outcomes related to anger issues. The objective of review is to provide comprehensive overview of anger management interventions for adolescents. Search was done using electronic databases such as Cochrane Library, OVID Medline, PubMed, CINAHL, EBSCOhost Springer, Wiley Online Library, ProQuest, ScienceDirect, and PsycINFO. Total 212 studies were found on anger management; twelve studies (five meta-analysis, one randomized controlled trial, one mixed methods, and five experimental) fulfilled the inclusion criteria of the study and these studies were included in the systematic review. Majority of the studies used cognitive behavioural therapy (CBT) as predominant therapeutic strategy for anger management for adolescents. Only few studies included rational emotive behavior therapy, social skill training, and education on anger. CBT with problem-solving skill training, communication skill training, and self-instruction was found to be effective in reducing anger problems in adolescents.



How to cite this article:
Anjanappa S, Govindan R, Munivenkatappa M. Anger management in adolescents: A systematic review.Indian J Psy Nsg 2020;17:51-56


How to cite this URL:
Anjanappa S, Govindan R, Munivenkatappa M. Anger management in adolescents: A systematic review. Indian J Psy Nsg [serial online] 2020 [cited 2020 Nov 24 ];17:51-56
Available from: https://www.ijpn.in/text.asp?2020/17/1/51/291619


Full Text



 Introduction



Adolescence or puberty is considered as a time of “storm and stress.” Adolescents in this period have difficulty in controlling their emotions and behave in defiant and unpredictable ways for no reason. This may cause many social problems.[1]

Children and adolescents lack adequate skills to recognize and cope with the emotions in general and anger specifically. This may often lead to aggression, bullying, and other disruptive behaviors.[2] These behaviors are frequently displayed in the school when children come across difficulties with peers or are unable to meet the academic demands.[3]

Absence of efficient skills in managing problems causes interpersonal difficulties and behavioral problems. Aggressive children and adolescents resort to weak, ineffective, and antisocial solutions due to the lack of effective social problem-solving strategies. Furthermore, they are unable to appraise or evaluate the effects of these solutions. These children consider an antisocial solution and aggressive behaviour as appropriate methods for solving the problem.[4],[5]

Hence, it is vital to provide help before they internalize maladaptive behaviors, which can consequently result in inefficient problem-solving and antisocial behaviors. Uncontrolled anger, aggression, severe acting out, and disruptive behavior are the most common reasons for referring adolescents to mental health services.[4]

In the recent years, a plethora of evidence has been generated through various studies, which have addressed identification and management of adolescents who have maladaptive anger regulation and expression. There is a necessity of therapeutic interventions addressing anger issues in adolescents to prevent future aggressive behaviors. Anger management training can be used as a therapeutic intervention to reduce maladjustment resulted by the interaction between variables of anger and maladjustment.[6] This review was conducted since the management and control of anger is often targeted as a treatment objective by school counselors, social workers, school health nurse, and psychologists when working with adolescents having anger problems. The objective of this systematic review was to synthesize the best available evidence on the effectiveness of various interventions on the anger or aggressive behavior of adolescents.

 Methods



Experimental studies, mixed methods, randomized controlled trial (RCT), and meta-analysis were included in the review. Based on the objectives of the current review, inclusion and exclusion criteria were prepared, and based on that, various databases were used in the selection of studies. The collected studies were checked for clarity and content and then used for the review.

Inclusion criteria

Studies where the participants were adolescentsStudies that assessed interventions for anger management. Interventions such as education on anger, cognitive behavior therapy, problem-solving skill training, communication skill training, role-play, and rational emotive behavior therapy (REBT)Both individual- and group-based interventionsStudies that have reduction in anger or aggression as primary or secondary outcomePublished in English language and peer reviewed from 2000 to 2018.

Exclusion criteria

Studies where the participants were adolescents with a developmental disorder, including autism spectrum disorder and intellectual disabilitiesStudies that included adultsUnpublished articles.

Electronic database searching

The databases searched

Cochrane Library, OVID Medline, PubMed, CINAHL, EBSCOhost Springer, Wiley Online Library, ProQuest, ScienceDirect, and PsycINFO.

Keywords used

Anger, adolescents, aggression, school going adolescents, cognitive behavior therapy for anger, problem solving skills, communication skills, and group therapy.

Data extraction and quality assessment

PRISMA flow diagram was used to select the articles [Figure 1]. Eligibility criteria were assessed for extracted data. Included studies were evaluated on the basis of relevance, appropriateness, clarity, and methodology. Those studies that were not meeting the criteria were excluded. Articles selected for review were assessed by two independent reviewers. The data extracted include participants, year of publication, study method, type of intervention, and outcome.{Figure 1}

Analysis

Steps in the analysis

Step I: Obtained data were tabulated and classified as author, study design, year of publication, setting, method, sample size, type of interventions, components of intervention, and outcome.

Step II: Identifying the findings of the studies. The studies were identified with their setting, method, sample size, type of intervention, and components of intervention.

Step III: Categorizing the findings. Findings were categorized under the headings of education on anger management, cognitive behavior therapy (CBT), REBT, and social skill training.

 Results



The review study included 212 potentially relevant articles. Out of which, 122 studies were excluded as duplicates, 65 articles were excluded as they did not meet the inclusion criteria, 13 articles did not mention the interventions, and 12 studies were included for the review.

Characteristics of the articles

Out of the 12 studies included in the review, five were experimental, one was RCT, one was a mixed method study, and five were meta-analysis. Majority of the interventions were conducted in the classroom setting. All the studies included adolescents of both genders as participants. These studies were published between 2000 and 2018 [Table 1].{Table 1}

Effectiveness of intervention

Effectiveness of education on anger management

The aim of anger management interventions are creating awareness on types, functions and meaning of anger, its effect on brain and body, and style of expression.[7],[8] The one RCT study had used education on anger management to reduce the anger and increase self-esteem. Totally six sessions were conducted in classroom for experimental group which comprised 30 students.[9]

Effectiveness of cognitive behavior therapy

Five meta-analysis and one mixed method study were reported that cognitive behavior therapy was effective in reducing anger among adolescents. Fossum et al. analyzed 65 studies (n = 4971), which included CBT, behavior therapy, and family therapy. Teachers reported that there was a change in aggression, social functioning, and reduction in parental distress.[10] Wilson and Lipsy (2008) examined 249 studies for efficacy of school based interventions. These interventions were divided into four groups depending on the methodology, participant and characteristics of intervention. The four intervention formats are universal programs, selected/indicated programme, special schools or classes, comprehensive/multimodal programme. Cognitive behavior therapy and social skill training was common in all four services. Both these interventions were effective in reducing the aggression in adolescents.[11] Another meta-analysis examined the efficacy of cognitive behavioral intervention and behavior therapy on aggression of adolescents. These interventions were delivered in group settings in schools.[12] Hoogsteder et al. conducted a meta-analysis, including six studies and 164 adolescents with the history of psychiatric disorder (oppositional defiant disorder, conduct disorder, and posttraumatic stress disorder), and examined the effectiveness of individually oriented treatment (which means that the intervention contained at least an individual component, possibly in combination with group and/or family therapy) with CBT elements for adolescents with severe aggression problems. This individually oriented treatment was effective in reducing the externalizing behavior, physical aggression, and verbal aggression.[13] Sukhodolsky et al. examined efficacy of CBT on 1953 adolescents. The intervention included skill training, problem-solving, affective education, and multimodal interventions. Skill training and multimodal treatments were more effective in reducing aggressive behavior and improving social skills. However, problem-solving treatments were more effective in reducing subjective anger experiences.[14] One mixed method study compared CBT and personal development interventions on adolescent's anger. Results revealed that CBT was effective in reducing the anger and increasing the self-esteem in comparison with personal development intervention.[15]

Effectiveness of rational emotive behavior therapy

Studies indicate that REBT can be effective for improving anger management in children.[16],[17] Studies have proved that REBT could be an effective addition to a program that teaches problem-solving skills.[18] Two experimental studies examined the effectiveness of REBT on anger level in adolescents. Interventions included REBT and application of problem-solving techniques to the management of angry affect and behavior. Changing beliefs about situations to reduce anger, building empathy, recognizing signs of anger, and practicing anger control through role-playing were also included with REBT. These interventions were conducted in school setting and were effective in reducing the anger in adolescents.[19],[20]

Other therapies

One experimental study used verbal expression methods, modeling, feedback, question and response, reinforcement and small group work on anger, and social adjustment among the adolescents. These interventions were effective in reducing anger and increasing social adjustment in adolescents.[21] Another experimental study used anger management skills for adolescents with problematic anger behavior. Anger management was effective in reducing the anger behavior in adolescents.[22] One more experimental study with the sample size of 60 included role-play, modeling, time-out, and feedback in anger management interventions.[23] These strategies were effective in reducing the anger in adolescents.

 Discussion



Anger control skills and assertiveness enable adolescents to cope with anger (e.g. one will be able to express ones' resentment constructively without violating another person' rights and hurting feelings). Training these skills based on cognitive behavioral theories helps the individual to recognize his/her own incorrect patterns of thought and inefficient behavior and then change them.[24]

The present review findings show that majority of the anger management studies used were predominantly cognitive behavioral method. Cognitive behavioral interventions target anger-inducing thoughts and habitual behavioral expression patterns. Individuals are assisted in identifying anger-inducing thoughts and behavioral expression pattern to replace them with realistic, value-based, coping, self-instruction, and modified behavior.[25] Intervention studies assessing the effectiveness of cognitive behavioral therapy have proved that it is effective in managing anger in healthy way among the aggressive individuals.[26]

Only a small number of studies included education on anger, REBT, family therapy, role-play, problem-solving skills, communication skills, and feedback. These noncognitive behavioral approaches were also effective in reduction of anger. Studies in the review suggest that combinations of cognitive behavioral therapy and problem-solving skills, communication skills, self-instruction, and role-play were very effective in reducing the anger or aggression.[10],[11],[12],[13],[14]

Based on the studies by Sharp and Flanagan et al., REBT programs may be effective in teaching children the principles of REBT. Such awareness may lead to an increase in the use of these principles for anger management, thus reducing aggressive behavior.[19],[20] REBT help adolescents to accept their flaws, behavioral errors, and environmental constraints, which is important in anger management.[27]

In the present review, extensive research has been done in evaluating cognitive behavioral therapy for anger management. From this, we can conclude that cognitive behavioral therapy is effective in reducing the anger and it enhances the coping skills among the adolescents.

Majority of the studies in the review conducted intervention in groups and only one study was conducted individually. It infers that group-based anger management interventions are more effective method for school-going adolescents rather than individual sessions.

Findings of this review show that interventions were conducted in classroom or school settings. We can assume that these settings are comfortable for the school-going adolescents than the hospital or clinic. Creating nonthreatening environment for interventions is necessary for effective results.

Limitations of review

This review has some limitations. First, this review included only published literature in English. This would have resulted in missing of some crucial information. Second, with regard to the intervention, review included anger management for nonclinical sample. Hence, it may limit the generalizability of interventions. Further, review is based on a small number of studies.

 Conclusion



Anger or aggression is a precursor of conduct disorder in adolescents. Early intervention helps the adolescents to manage their anger in healthy ways. Findings of the review provide empirical evidence for CBT as an effective intervention for anger management among adolescents. This review suggest that evidence-based anger management interventions are essential for adolescents to manage their anger effectively. School health nurse and school counselors can use these evidence-based interventions to help the students to manage their anger and prevent occurrence of negative consequences in school environment related to anger issues.

Acknowledgment

We acknowledge the support of the librarians of NIMHANS Information center.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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