Skip to main content
SpringerLink
Log in

Treatment moderators of cognitive behavior therapy to reduce aggressive behavior: a meta-analysis

  • Review
  • Published:
European Child & Adolescent Psychiatry Aims and scope Submit manuscript

Abstract

Maladaptive aggression in adolescents is an increasing public health concern. Cognitive Behavior Therapy (CBT) is one of the most common and promising treatments of aggression. However, there is a lack of information on predictors of treatment response regarding CBT. Therefore, a meta-analysis was performed examining the role of predictors on treatment response of CBT. Twenty-five studies were evaluated (including 2,302 participants; 1,580 boys and 722 girls), and retrieved through searches on PubMed, PsycINFO and EMBASE. Effect sizes were calculated for studies that met inclusion criteria. Study population differences and specific CBT characteristics were examined for their explanatory power. There was substantial variation across studies in design and outcome variables. The meta-analysis showed a medium treatment effect for CBT to reduce aggression (Cohen’d = 0.50). No predictors of treatment response were found in the meta-analysis. Only two studies did examine whether proactive versus reactive aggression could be a moderator of treatment outcome, and no effect was found of this subtyping of aggression. These study results suggest that CBT is effective in reducing maladaptive aggression. Furthermore, treatment setting and duration did not seem to influence treatment effect, which shows the need for development of more cost-effective and less-invasive interventions. More research is needed on moderators of outcome of CBT, including proactive versus reactive aggression. This requires better standardization of design, predictors, and outcome measures across studies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Armbruster MA, Sukhodolsky DG, Michalsen R (2004) The impact of managed care on children’s outpatient treatment: a comparison study of treatment outcome before and after managed care. Am J Orthopsychiatry 74(1):5–13

    Article  PubMed  Google Scholar 

  2. Rutter M, Bishop D, Pine D, Scott S, Stevenson JS, Taylor EA, Thapar A (2010) Rutter’s child and adolescent psychiatry. Wiley, Oxford

    Google Scholar 

  3. Gannon TA, Ward T, Beech AR, Fisher D (2007) Aggressive offenders’ cognition: theory, research and practice. Wiley, Chichester

    Book  Google Scholar 

  4. Romeo R, Knapp M, Scott S (2006) Economic cost of severe antisocial behaviour in children—and who pays it. Br J Psychiatry 18(8):547–553

    Article  Google Scholar 

  5. Buitelaar JK, Smeets KC, Herpers P, Scheepers F, Glennon J, Rommelse NNJ (2013) Conduct disorders. Eur Child Adolesc Psychiatry 22(1):49–54

    Article  Google Scholar 

  6. Frick PJ, Viding E (2009) Antisocial behavior from a developmental psychopathology perspective. Dev Psychopathol 21(04):1111–1131

    Article  PubMed  Google Scholar 

  7. Monahan KC, Steinberg L, Cauffman E (2009) Affiliation with antisocial peers, susceptibility to peer influence, and antisocial behavior during the transition to adulthood. Dev Psychol 45(6):1520–1530

    Article  PubMed Central  PubMed  Google Scholar 

  8. Armelius BA, Andreassen TH (2007) Cognitive-behavioral treatment for antisocial behavior in youth in residental treatment. Cochrane Database Syst Rev 4:1–35

    Google Scholar 

  9. Connor DF, Carlson GA, Chang KD, Daniolos PT, Ferziger R, Findling RL, Hutchinson JG, Malone RP, Halperin JM, Plattner B, Post RM, Reynolds DL, Rogers KM, Saxena K, Steiner H (2006) Juvenile maladaptive aggression: a review of prevention, treatment, and service configuration and a proposed research agenda. J Clin Psychiatry 67(5):808–820

    Article  CAS  PubMed  Google Scholar 

  10. Barzman DH, Findling RL (2008) Pharmacological treatment of pathologic aggression in children. Int Rev Psychiatry 20:151–157

    Article  PubMed  Google Scholar 

  11. Mattaini MA, McGuire MS (2006) Behavioral strategies for constructing nonviolent cultures with youth: a review. Behav Modif 30(2):184–224

    Article  PubMed  Google Scholar 

  12. Blake CS, Hamrin V (2007) Current approaches to the assessment and management of anger and aggression in youth: a review. J Child Adolesc Psychiatr Nurs 20(4):209–221

    Article  PubMed  Google Scholar 

  13. Aman MG, Bukstein OG, Gadow KD, LE Arnold, Molina BS, McNamara NK, Rundberg-Rivera EV, Li X, Kipp H, Schneider J, Butter EM, Baker J, Sprafkin J, Rice RR Jr, Bangalore SS, Farmer CA, Austin AB, Buchan-Page KA, Brown NV, Hurt EA, Grondhuis SN, Findling RL (2014) What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry 53(1):47–60. doi:10.1016/j.jaac.2013.09.022 e41

    Article  PubMed Central  PubMed  Google Scholar 

  14. Sukhodolsky DG, Kassinove H, Gorman BS (2004) Cognitive-behavioral therapy for anger in children and adolescents: a meta-analysis. Aggress Viol Behav 9(3):247–269

    Article  Google Scholar 

  15. Fossum S, Handegård BH, Martinussen M, Mørch WT (2008) Psychosocial interventions for disruptive and aggressive behaviour in children and adolescents: a meta-analysis. Eur Child Adolesc Psychiatry 17:438–451

    Article  PubMed  Google Scholar 

  16. Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, Stevenson J, Danckaerts M, van der Oord S, Dopfner M, Dittmann RW, Simonoff E, Zuddas A, Banaschewski T, Buitelaar J, Coghill D, Hollis C, Konofal E, Lecendreux M, Wong IC, Sergeant J (2013) Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 170(3):275–289

    Article  PubMed  Google Scholar 

  17. Polman H, Orobio de Castro B, Koops W, van Boxtel HW, Merk WM (2007) A meta-analysis of the distinction between reactive and pro active aggression in children and adolescents. J Abnorm Child Psychol 35:522–535

    Article  PubMed  Google Scholar 

  18. Vitaro F, Brendgen M, Tremblay RE (2002) Reactively and proactively aggressive children: antecedent and subsequent characteristics. J Child Psychol Psychiatry 43(4):495–505

    Article  PubMed  Google Scholar 

  19. Stanford MS, Houston RJ, Mathias CW, Villemarette-Pittman NR, Helfritz LE, Conklin SM (2003) Characterizing aggressive behavior. Assessment 10(2):183–190

    Article  PubMed  Google Scholar 

  20. Kockler TR, Stanford MS, Nelson CE, Meloy JR, Sanford K (2006) Characterizing Aggressive Behavior in a Forensic Population. Am J Orthopsychiatry 76(1):80–85

    Article  PubMed  Google Scholar 

  21. Frick PJ, Ellis M (1999) Callous-unemotional traits and subtypes of conduct disorder. Clin Child Fam Psychol Rev 2(3):149–168

    Article  CAS  PubMed  Google Scholar 

  22. Blair RJ (2001) Neurocognitive models of aggression, the antisocial personality disorders, and psychopathy. J Neurol Neurosurg Psychiatry 71(6):727–731

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Blair RJ, Peschardt KS, Budhani S, Mitchell DG, Pine DS (2006) The development of psychopathy. J Child Psychol Psychiatry 47(3–4):262–276

    Article  CAS  PubMed  Google Scholar 

  24. Vitaro F, Brendgen M, Barker ED (2006) Subtypes of aggressive behaviors: a developmental perspective. Int J Behav Dev 30(1):12–19

    Article  Google Scholar 

  25. Barker ED, Vitaro F, Lacourse E, Fontaine NMG, Carbonneau R, Tremblay RE (2010) Testing the developmental distinctiveness of male proactive and reactive aggression with a nested longitudinal experimental intervention. Aggress Behav 36:127–140

    Article  PubMed  Google Scholar 

  26. Haas SM, Waschbusch DA, Pelham WE Jr, King S, Andrade BF, Carrey NJ (2011) Treatment response in CP/ADHD children with callous/unemotional traits. J Abnorm Child Psychol 39:541–552

    Article  PubMed  Google Scholar 

  27. Masi G, Manfredi A, Milone A, Muatori P, Polidori L, Ruglioni L, Muratori F (2011) Predictors of nonresponse to psychosocial treatment in children and adolescents with disruptive behaviour disorders. J Child Adolesc Psychopharmacol 21(1):51–55

    Article  PubMed  Google Scholar 

  28. Card NA, Little TD (2006) Proactive and reactive aggression in childhood and adolescence: a meta-analysis of differential relations with psychosocial adjustment. Int J Behav Dev 30(5):466–480. doi:10.1177/0165025406071904

    Article  Google Scholar 

  29. Poulin F, Boivin M (2000) The role of proactive and reactive aggression in the formation and development of boys’ friendships. Dev Psychol 36(2):233–240

    Article  CAS  PubMed  Google Scholar 

  30. Bushman BJ, Anderson CA (2001) Is it time to pull the plug on the hostile versus instrumental aggression dichotomy? Psychol Rev 108(1):273–279

    Article  CAS  PubMed  Google Scholar 

  31. Morris SB (2008) Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods 11(2):364–386

    Article  Google Scholar 

  32. Lipsey MW, Landenberger NA, Wilson SJ (2007) Effects of cognitive-behavioral programs for criminal offenders. Campbell Syst Rev 6. doi:10.4073/csr.2007.6

  33. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17(1):1–12

    Article  CAS  PubMed  Google Scholar 

  34. Cohen J (1988) Statistical power analysis for the behavioral sciences. Lawrence Erlbaum Associations, Hillsdale

    Google Scholar 

  35. Nordic Cochrane Centre TCC (2011) Review Manager (RevMan). (Version 5.1)

  36. Down R, Willner P, Watts L, Griffiths J (2011) Anger Management groups for adolescents: a mixed-methods study of efficacy and treatment preferences. Clin Child Psychol Psychiatry 16(1):33–52

    Article  PubMed  Google Scholar 

  37. Van Manen TG, Prins PJ, Emmelkamp PM (2004) Reducing aggressive behavior in boys with a social cognitive group treatment: results of a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry 43(12):1478–1487

    Article  PubMed  Google Scholar 

  38. Landenberger NA, Lipsey MW (2005) The positive effects of cognitive–behavioral programs for offenders: a meta-analysis of factors associated with effective treatment. J Exp Criminol 1:451–476

    Article  Google Scholar 

  39. McCart MR, Priester PE, Davies WH, Azen R (2006) Differential effectiveness of behavioral parent-training and cognitive-behavioral therapy for antisocial youth: a meta-analysis. J Abnorm Child Psychol 34(4):527–543

    Article  PubMed  Google Scholar 

  40. Dekovic M, Slagt MI, Asscher JJ, Boendermaker L, Eichelsheim VI, Prinzie P (2011) Effects of early prevention programs on adult criminal offending: a meta-analysis. Clin Psychol Rev 31(4):532–544. doi:10.1016/j.cpr.2010.12.003

    Article  PubMed  Google Scholar 

  41. van der Put CE, Asscher JJ, Stams GJ, van der Laan PH, Breuk R, Jongman E, Doreleijers T (2013) Recidivism after treatment in a forensic youth-psychiatric setting: the effect of treatment characteristics. Int J Offender Ther Comp Criminol 57(9):1120–1139. doi:10.1177/0306624x12452389

    Article  PubMed  Google Scholar 

  42. Dickersin K (1990) The existence of publication bias and risk factors for its occurrence. J Am Med Assoc 263(10):1385–1389

    Article  CAS  Google Scholar 

  43. Hopewell S, McDonald S, Clarke MJ, Egger M (2007) Grey literature in meta-analyses of randomized trials of health care interventions. Cochrane Database Syst Rev 2:1–16

    Google Scholar 

Studies included in the meta-analysis

  1. August GJ, Lee SS, Bloomquist ML, Realmuto GM, ektner JM (2003) Dissemination of an evidence-based prevention innovation for aggressive children living in culturally diverse, urban neighborhoods: the Early Risers effectiveness study. Prev Sci 4(4):271–286

    Article  PubMed  Google Scholar 

  2. August GJ, Realmuto GM, Hektner JM, Bloomquist ML (2001) An integrated components preventive intervention for aggressive elementary school children: the early risers program. J Consult Clin Psychol 69(4):614–626

    Article  CAS  PubMed  Google Scholar 

  3. Brotman LM, Klein RG, Kamboukos D, Brown EJ, Coard SI, Sosinsky LS (2003) Preventive intervention for urban, low-income preschoolers at familial risk for conduct problems: a randomized pilot study. J Clin Child Adolesc Psychol 32(2):246–257

    Article  PubMed  Google Scholar 

  4. Butler S, Baruch G, Hickey N (2011) A randomized controlled trial of multisystemic therapy and a statutory therapeutic intervention for young offenders. J Am Acad Child Adolesc Psychiatry 50(1220–1235):e1222

    Google Scholar 

  5. Carpenter EM (2002) A curriculum-based approach for social-cognitive skills training: an intervention targeting aggression in Head Start preschoolers. University of Maine

  6. Feinfield KA, Baker BL (2004) Empirical support for a treatment program for families of young children with externalizing problems. J Clin Child Adolesc Psychol 33(1):182–195

    Article  PubMed  Google Scholar 

  7. Larsson B, Fossum S, Clifford G, Drugli MB, Handegård BH, Mørch WT (2009) Treatment of oppositional defiant and conduct problems in young Norwegian children : results of a randomized controlled trial. Eur Child Adolesc Psychiatry 18(1):42–52

    Article  PubMed  Google Scholar 

  8. Lipman EL, Boyle MH, Cunningham C, Kenny M, Sniderman C, Duku E, Mills B, Evans P, Waymouth M (2006) Testing effectiveness of a community-based aggression management program for children 7–11 years old and their families. J Am Acad Child Adolesc Psychiatry 45(9):1085–1093

    Article  PubMed  Google Scholar 

  9. Mitchell P, Smedley K, Kenning C, McKee A, Woods D, Rennie CE, Bell RV, Aryamanesh M, Dolan M (2011) Cognitive behaviour therapy for adolescent offenders with mental health problems in custody. J Adolesc Health 34(3):433–443

    Article  Google Scholar 

  10. Nickel M, Luley J, Krawczyk J, Nickel C, Widermann C, Lahmann C, Muehlbacher M, Forthuber P, Kettler C, Leiberich P, Tritt K, Mitterlehner F, Kaplan P, Pedrosa Gil F, Rother W, Loew T (2006) Bullying girls—changes after brief strategic family therapy: a randomized, prospective, controlled trial with 1-year follow-up. Psychother Psychosom 75(1):47–55

    Article  PubMed  Google Scholar 

  11. Nickel MK, Krawczyk J, Nickel C, Forthuber P, Kettler C, Leiberich P, Muehlbacher M, Tritt K, Mitterlehner FO, Lahmann C, Rother WK, Loew TH (2005) Anger, interpersonal relationships, and health-related quality of life in bullying boys who are treated with outpatient family therapy: a randomized, prospective, controlled trial with 1 year of follow-up. Pediatrics 116(2):247–254

    Article  Google Scholar 

  12. Nickel MK, Muehlbacher M, Kaplan P, Krawczyk J, Buschmann W, Kettler C, Rother N, Egger C, Rother WK, Loew TK, Nickel C (2006) Influence of family therapy on bullying behaviour, cortisol secretion, anger, and quality of life in bullying male adolescents: a randomized, prospective, controlled study. Can J Psychiatry 51(6):355–362

    PubMed  Google Scholar 

  13. Nickel MK, Nickel C, Leiberick R, Tritt K, Mitterlehner FO, Lahmann C, Rother WK, Loew TH (2005) Aggressive female youth benefit from outpatient family therapy: a randomized, prospective, controlled trial. Pediatri Int 47(2):167–171

    Article  Google Scholar 

  14. O’Neal CR, Brotman LM, Huang KY, Gouley KK, Kamboukos D, Calzada EJ, Pine DS (2010) Understanding relations among early family environment, cortisol response, and child aggression via a prevention experiment. Child Dev 81(1):290–305

    Article  PubMed Central  PubMed  Google Scholar 

  15. Ogden T, Hagen KA (2006) Multisystemic treatment of serious behaviour problems in youth: sustainability of effectiveness 2 years after intake. Child Adolesc Mental Health 11(3):142–149

    Article  Google Scholar 

  16. Pepler D, Walsh M, Yuile A, Levene K, Jiang D, Vaughan A, Webber J (2010) Bridging the gender gap: interventions with aggressive girls and their parents. Prev Sci 11(3):229–238

    Article  PubMed  Google Scholar 

  17. Rowland MD, Halliday-Boykins CA, Henggeler SW, Cunningham PB, Lee TG, Kruesi MJP, Shapiro SB (2005) A randomized trial of multisystemic therapy with Hawaii’s felix class youths. J Emot Behav Disord 13(1):13–23

    Article  Google Scholar 

  18. Santisteban DA, Coatsworth JD, Perez-Vidal A, Kurtines WM, Schwartz SJ, LaPerriere A, Szapocznik J (2003) Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use. J Fam Psychol 17(1):121–133

    Article  PubMed Central  PubMed  Google Scholar 

  19. Schechtman Z (2000) An innovative intervention for treatment of children and adolescent aggression: an outcome study. Psychol Schools 37(2):157–167

    Article  Google Scholar 

  20. Sukhodolsky DG, Golub A, Stone EC, Orban L (2005) Dismantling anger control training for children: a randomized pilot study of social problem-solving versus social skills training components. Behav Ther 36:15–23

    Article  Google Scholar 

  21. Sundell K, Hansson K, Löfholm CA, Olsson T, Gustle LH, Kadesjö C (2008) The transportability of multisystemic therapy to Sweden: short-term results from a randomized trial of conduct-disordered youths. J Fam Psychol 22(4):550–560

    Article  PubMed  Google Scholar 

  22. Webster-Stratton C, Reid J, Hammond M (2001) Social skills and problem-solving training for children with early-onset conduct problems: who benefits? J Child Psychol Psychiatry 42(7):943–952

    Article  CAS  PubMed  Google Scholar 

  23. van de Wiel NM, Matthys W, Cohen-Kettenis PT, Maassen GH, Lochman JE, van Engeland H (2007) The effectiveness of an experimental treatment when compared to care as usual depends on the type of care as usual. Behav Modif 31(3):298–312

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

Jan K. Buitelaar has been a consultant to/member of advisory board of/and/or speaker for Janssen Cilag BV, Eli Lilly, Bristol-Myer Squibb, Shering Plough, UCB, Shire, Novartis and Servier. He is not an employee of any of these companies, and not a stock shareholder of any of these companies. He has no other financial or material support, including expert testimony, patents, royalties. F.E.Scheepers has travel support and is a speaker for Eli Lilly. K. Smeets, A.Leeijen, M. van der Molen and N. Rommelse state no conflict of interest.

Author information

Authors and Affiliations

  1. Karakter Child and Adolescent Psychiatry University Centre, Reinier Postlaan 12, 6525 GC, Nijmegen, The Netherlands

    Kirsten C. Smeets, Jan K. Buitelaar & Nanda N. J. Rommelse

  2. Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands

    Jan K. Buitelaar

  3. Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands

    Nanda N. J. Rommelse

  4. Department of Psychiatry, Rudolf Magnus Institute of Neuroscience, UMC Utrecht, Utrecht, The Netherlands

    Floor E. Scheepers

  5. Faculty of Psychology and Education and the EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, The Netherlands

    Mariët J. van der Molen

  6. Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands

    Anouk A. M. Leeijen

Authors
  1. Kirsten C. Smeets
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anouk A. M. Leeijen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mariët J. van der Molen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Floor E. Scheepers
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jan K. Buitelaar
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nanda N. J. Rommelse
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kirsten C. Smeets.

Additional information

Trial registration: ISRCTN21681959.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 32 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Smeets, K.C., Leeijen, A.A.M., van der Molen, M.J. et al. Treatment moderators of cognitive behavior therapy to reduce aggressive behavior: a meta-analysis. Eur Child Adolesc Psychiatry 24, 255–264 (2015). https://doi.org/10.1007/s00787-014-0592-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00787-014-0592-1

Keywords

Search

Navigation