Cognitive behavioral skill-based training program for enhancing anger control among youth.

BACKGROUND: Anger expression and its control among youth is a major concern for the health professionals. There is dearth of intervention-based study in Indian context. The present work aims to evolve an intervention module for management of anger among youth in India.
MATERIALS AND METHODS: The present module has been validated on 100 individuals with inclusion criteria of age from 18 to 25 years and the individuals with dependence on psychoactive drugs and refusal to participate were excluded from the study. The Anger data sheet, Buss-Perry Aggression Questionnaire, and State Trait Anger Expression Inventory were administered at baseline as well as at 1-month interval after 6 sessions of intervention. The 82 participants completed postassessment and 18 participants were dropouts of the follow-up sessions.
RESULTS: Pre-post cognitive therapy based anger management intervention program showed the difference in the domains of resilience; clinical anger, state and trait anger and anger control in.
CONCLUSIONS: The study implies the need for community-based sensitization for issues related to anger expression and facilitation of approaches to promote adaptive anger control among youth. Copyright:

Aggression can be defined as any behavior intended to hurt others. In other words, human aggression is any behavior directed toward another individual that is carried out with the proximate (immediate) intent to cause harm. In addition, the perpetrator must believe that the behavior will harm the target, and that, the target is motivated to avoid the behavior.[1234]

Society has seen increased incidents of aggression/violence among youth. It includes various behaviors such as slapping, hitting, rape, recklessness in driving, and shooting on school. The problem of youth cannot be seen in isolation from other problem behavior. They also often display other problems such as truancy, dropping out from school, road rage, and other high-risk behaviors. The western researchers had focused on the prevalence and correlates of aggression in youth[567] and its association with other factors such as peer influence, antisocial personality traits, depression, socioeconomic status, gender, single parent violence, substance use, maternal depression, parental violence, peer deviancy, peer attitudes, peer status, popularity in the peer group,[89] peer victimization,[10111213] and aggression among youth.[14]

In an Indian context, study was carried out for the prevalence and nature of violence experienced by the children in families in Tripura, India and its relationship with socioeconomic factors. Male children were more likely to be victims of psychological and physical violence while female children experienced more sexual violence. Relationship has been seen between violence against children and nuclear family, uncongenial, and/or disturbed family environment and dominating, short-tempered, and/or aggressive parent personality, irrespective of the nature of the violence. Physical violence was found to be more prevalent in high-income families while children from the lower income group of families experienced more psychological violence. Sexual violence was found to be equally prevalent in all socioeconomic groups. It also revealed that academic performance of violence-experienced children, irrespective of nature of violence and socioeconomic groups was poor compared to academic performance of nonviolence-experienced children.[15] There is an association between both forms (overt and relational) of aggression and perceived popularity and between relational aggression and social preference.[16] Males reported more relational aggression in romantic relationship.[17] Personality characteristics such as openness, agreeableness, and conscientiousness were found to be negatively correlated with all forms of aggression. The results indicated significant differences between men and women with respect to aggression in romantic relationships. The personality factor “neuroticism” was negatively associated with relationship satisfaction. Higher relationship satisfaction indicated lower level of aggression in romantic relationships.[18]

In India, there is an exploration of beliefs about anger among a group of adolescent male offenders temporarily residing in a presentencing institution. Perceived violations of family honor were cited as the most common elicitors of anger, and although anger was considered “bad,” it was expressed through aggression.[19] The risk factors of the youth aggressions were identified as physical abuse in childhood, substance abuse such as alcohol and tobacco, negative peer influence, family violence, academic disturbance, psychological problems like attention deficit-hyperactivity disorder, suspicious, loneliness, mood disturbance, negative childhood experience and TV and media.[20]

Narcissistic children were more aggressive than others, but only after they had been shamed. Low self-esteem did not lead to aggression. Narcissism in combination with high self-esteem led to exceptionally high aggression.[21] Reducing beliefs about aggression is a promising strategy for primary prevention aimed at children and young adolescents but that secondary prevention and treatment should target factors other than beliefs legitimizing aggression risk bringing about reduced levels of aggression.[22]

There was no significant difference between interventions although programs that used nontheory-based interventions focused on at-risk and older children and employed intervention had slightly stronger effects in reducing aggression and violence. Interventions using a single approach had a mild positive effect on decreasing aggressive.[23]

Society has seen increased incidents of aggression/violence among youth. It includes various behaviors such as slapping, hitting, rape, recklessness in driving, and shooting on school. The problem of youth cannot be seen in isolation from other problem behavior. They also often display other problems such as truancy dropping out from school, road rage, and other high-risk behaviors. The limited research in India about the prevalence of anger in youth associated risk factors of aggression and published work on the prevention of anger among youth. The increasing crime rates and violent activities of youth in India have made the researchers to focus on anger among youth. There is a need for prevention and intervention modules for youth in Indian context. This present study aims to develop an intervention module for aggression among youth in India.

MATERIALS AND METHODS

Aim

To develop the intervention module for management of anger among youth.

Objectives

To identify risk factors associated with anger among youth

To identify factors which prevent anger among youth

To assess the efficacy of the evolved module for prevention of anger among youth.

Sample

The present module has been validated on 100 individuals among 1000 individuals from Bangalore, India, taken from the study prevalence and correlates of anger among youth in India. The sample consists of 6500 individuals, from which 1024 protocols were incomplete so it was not considered for analysis; a total of 5476 data were considered for analysis. 2785 were male and 2691 were female participants for the study, with inclusion criteria of age: 18–25 years and ability to read and write English or Kannada. The individuals with dependence on psychoactive drugs and refusal to participate were excluded. The present study had approval of Institute Ethic Committee.

Tools

Anger data sheet was developed by the investigator. It gives information about the individual, their socio demographic variable, situations associated with aggression, type of aggression, style of expression of anger, control over aggressive ideation, and protective factors for controlling the aggression, and risk factors such as substance abuse, mood disturbance, childhood experience, academic effects, family influence, peer influence, and media influence were involved.

Buss–Perry aggression questionnaire[24]

It represents the revision of Buss–Durkee Hostility Inventory. It has 29 items. It has been scored on 5 point scale. Test reliability was 0.71 for Anger and 0.90 for physical aggression and total scale.

State Trait Anger Expression Inventory-2[25]

The State Trait Anger Expression Inventory-2 (STAXI-2) measure the experience and expression of anger, and it is 57-item self-report questionnaires. It can be used with adult population. It consists of six scales and an anger expression index. The scales are state anger, trait anger, anger expression – out, anger expression – in, anger control – out, and anger control – in and anger expression index. Permission to copy the response sheet was obtained from the author.

Resilience

It had been developed by org-health.[26] Permission to use was obtained from the agency.

The resilience assessment measures the ability of coping stressful situations. It has 8 dimensions which are self-assurance, personal vision, flexible and adaptable, organized, problem solver, interpersonal competence, socially connected and active. There are 32 items each item has 5 point rating from strongly disagree to strongly agree.

Procedure

The present sample of 100 (for the validation of anger management program) was part of the survey which was carried out in various parts for assessing the correlates of anger among 5476 youth. In this sample, 1000 individuals were taken from the Bangalore, India. After obtaining their informed consent, group administration of Buss–Perry Aggression Questionnaire scale, STAXI and resilience scale were carried out. 100 individuals, who score high on Buss–Perry Aggression Questionnaire as well as on STAXI were taken for the intervention. Postassessment at 1-month follow-up using Buss–Perry Aggression Questionnaire, STAXI, and resilience scale were carried out.

The content for the program was evolved through seven focus group discussions of mental health experts/counselors (having experience of 5 or more years), review of literature, and available treatment modules. The mental health professional's inputs were taken for the evolved components. Based on the inputs, six sessions program was evolved for the study.

The six sessions group program (each session was attended by 6–20 subjects). Each session was or 60–90 min duration.

Session 1 Guidelines for group moderators, Group rules, and Anger – a problem, Aggression versus Hostility, Myths (anger is hereditary in nature. It is inherited and cannot be modified; People must show aggression to fulfill their desires and goals and men get mad, women get depressed etc., short-term gains, long-term consequences, monitoring anger, postsession assignment.

Session 2 guidelines for group moderators, causes of anger, social – cognitive model of anger and aggression, triggering situations, triggering cues, review exercise, postsession assignment.

Session 3 guidelines for group moderators, review exercise, deep breathing exercise, time-out, and postsession assignment.

Session 4 guidelines for group moderators, review exercise, irrational cognitions, cognitive restructuring, postsession assignment.

Session 5 guidelines for group moderators, review exercise, family, assertiveness training/problem solving, postsession assignment.

Session 6 guidelines for group moderators, review exercise, anger management plans, postsession assignment.

The follow-up assessment was done using resilience, clinical anger scale, Buss and Perry Aggression Questionnaire and STAXI to assess the efficacy of program at one month interval after intervention. The 82 participants completed postassessment, 18 participants were drop outs of the follow-up sessions.

Data analysis

Data were analyzed using IBM SPSS statistics Base 22.00 by SPSS South Asia Pvt Ltd, Bangalore, Karnataka, India; all the nominal and ordinal measure were analyzed using the suitable statistical procedure such as frequency and percentage. Interval and ratio scale measure was analyzed using descriptive statistics. Comparative analysis was carried out by Pearson correlation coefficient, subgroup analysis; ANOVA and Chi-square were also carried out.

RESULTS

982 individuals were surveyed from Bangalore. On sociodemographic variables, analysis showed that, the mean age of the sample was 19.54 years. Only 0.3% were illiterate, 92% were single, 3.9% were married. 1.8% was in the live in relationship, and 74% were from the nuclear family.

Table 1 shows significance at 0.001 levels for the domains of state anger, state physical, physical aggression, hostility, and aggression total.

Table 1

Distribution of anger score among individuals

Domains	Gender	n	Mean (SD)	Significance
State anger	Male	478	23.68 (8.075)	0.000*
	Female	504	21.71 (7.27)	0.000*
State feeling	Male	478	8.31 (2.917)	0.010
	Female	504	7.85 (2.770)	0.011
State verbal	Male	478	7.72 (3.099)	0.019
	Female	504	7.27 (2.999)	0.019
State physical	Male	478	7.64 (3.245)	0.000*
	Female	504	6.57 (2.633)	0.000*
Trait anger	Male	478	19.46/7.64 (5.720/3.245)	0.063
	Female	504	18.81/6.57 (5.197/2.633)	0.064
Trait temperament	Male	478	7.18 (2.493)	0.079
	Female	504	6.91 (2.348)	0.080
Trait reaction	Male	478	8.82 (2.922)	0.702
	Female	504	8.88 (2.765)	0.703
Anger expression out	Male	478	16.00 (3.966)	0.700
	Female	504	15.90 (4.103)	0.699
Anger expression in	Male	478	16.48 (4.060)	0.871
	Female	504	16.43 (4.348)	0.870
Anger control out	Male	478	20.69 (5.014)	0.804
	Female	504	20.61 (4.809)	0.804
Anger control in	Male	478	19.70 (4.931)	0.241
	Female	504	20.05 (4.669)	0.242
Anger total	Male	478	40.07 (9.325)	0.485
	Female	504	39.66 (9.434)	0.485
Physical aggression	Male	478	24.58 (5.668)	0.000*
	Female	504	22.22 (6.360)	0.000*
Hostility	Male	478	23.33 (5.911)	0.004*
	Female	504	22.25 (5.730)	0.004*
Verbal aggression	Male	478	14.98 (3.957)	0.018
	Female	504	14.36 (4.275)	0.018
Aggression total	Male	478	82.38 (16.035)	0.000*
	Female	504	77.56 (16.281)	0.000*

*significance level <0.05, *Significance level <.0.01

Table 2 indicates that there is significant difference (P = 0.011) in the pre- and post- assessment of the participants in resilience; clinical anger, state and trait anger and anger control in.

Table 2

Comparison of group (n=100) pre- and post-assessment of the intervention

Variables	Mean		t	Significance (two-tailed)
	Preassessment	Postassessment
Total of resilience	106.53	114.63	−2.609	0.011*
Anger	20.62	19.42	1.613	0.111
Physical aggression	25.06	25.09	−0.040	0.968
Hostility	23.71	23.06	0.765	0.446
Verbal aggression	15.24	15.52	−0.406	0.686
Aggression total	84.64	83.10	0.599	0.551
Clinical anger total	22.91	16.29	4.225	0.000**
State anger	27.52	23.93	2.714	0.008**
Trait anger	21.48	18.67	3.399	0.001**
Anger expression out	16.62	17.70	−1.625	0.108
Anger expression in	16.40	17.42	−1.528	0.130
Anger control in	17.71	19.20	−2.129	0.036*
Anger control out	19.21	19.43	−0.301	0.764
Anger total	44.08	44.48	−0.305	0.761

*Significance level 0.05, **Significance level 0.01

DISCUSSION AND CONCLUSIONS

The study document the presence of state anger, state physical, physical aggression, and hostility among youth [Table 1]. Pre-post cognitive behavioral therapy based anger management intervention showed difference in the domains of resilience; clinical anger, state and trait anger and anger control in [Table 2]. Even though there is no significant difference of Buss and Perry Aggression Scale in the pre- and post-assessment, there is difference in the mean scores of aggression in both pre- and post-assessment. The mean score comparison indicates there low scores in postassessment of the study. The intervention has shown impact in other studies also. The students who displayed inappropriate expressions of anger benefited from the 8-week cognitive-behavioral intervention program. It was found to be more successful in treating the situational aspects of anger expression than in treating its underlying dispositions. Treatment group showed declined of 57% for anger frequency, 56% for anger duration, and 21% for anger intensity for treatment group.[2728] Cognitive-behavioral intervention was found to be effective for aggressive driving behaviors in the general population. Total driving anger significantly decreased as well as anger as a reaction to hostile gestures, anger as a response to illegal driving, anger precipitated by slow driving, anger precipitated by discourtesy, and anger caused by traffic obstructions.[29] The treatment approaches providing relaxation, cognitive, and behavior coping skills reported significant reductions in the tendency to express anger outwardly and negatively. Interventions that combine relaxation, cognitive, and social skills training would seem particularly appropriate for participants who possess both heightened cognitive/emotional-physiological involvement and lowered interpersonal skills at handling interpersonal conflict.[30]

Whereas the characteristics of successful school-based violence prevention programs were evaluated using twenty-six randomized controlled trial, school-based studies that were designed to reduce externalizing, aggressive, and violent behavior between the 1st and 11th grades. The effects of 5 program characteristics by comparing results of intervention groups to control groups (no intervention) after intervention using a meta-analysis. Electronic databases and bibliographies were systematically searched, and a standardized mean difference was used for analysis. There was no significant difference between interventions, although programs that used nontheory-based interventions, focused on at-risk and older children, and employed intervention specialists had slightly stronger effects in reducing aggression and violence. Interventions using a single approach had a mild positive effect on decreasing aggressive and violent behavior (effect size = −0.15, 95% confidence interval = −0.29–−0.02, P = 0.03).[31] A randomized controlled of 125 male veterans with posttraumatic stress disorder and anger difficulties were conducted at 3 veterans' affairs outpatient clinical. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via video teleconferencing (n = 61). Participants were assessed at baseline, mid treatment (3 weeks), post treatment. The primary clinical outcomes was reduction of anger difficulties as measured by the anger expression and trait anger subscales of the STAXI-2 and by the Novaco anger scale total score. The participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with post treatment 3 and 6 months interval, posttreatment effect sizes range from 0.12 to 0.63.[32] 252 boys in age group of 6–11 were recruited for of stop now and plan (SNAP) program and measures were administered in four waves, at baseline and at 3, 9 and 15 months after baseline. SNAP was associated with improved problem solving skills, pro social behavior, and emotion regulation skills and reduced parental stress and partially meditated improvement in child aggression.[33] The aggression replacement therapy is a multimodal program aiming at replacing antisocial behaviors by actively teaching desirable behavior. The systematic review examines the effect of Aggression Replacement Training (ART) on antisocial behavior in young and adults. This review identified 16 studies with methodological quality and postintervention follow-up of studies. They concluded that there is insufficient evidence based to substantiate the hypothesis that ART has positive impact on recidivism, self-control, social skills, moral development in adolescents and adults.[34] The review of scientific literature demonstrating that within each of these disorders like explosive disorders, oppositional deficient disorder, disruptive mood disorder, bipolar disorder, bipolar personality disorder, anger is a central clinical feature that is highly predictive of important outcomes.[35] There is a mechanistic model of irritability that integrates clinical and transactional neuroscience research. Two complimentary conceptualizations of pathological irritability are proposed, and suggested that relative to healthy children, irritable children have deficient reward learning and elevated sensitivity to reward receipt and omission. These deficits are associated with dysfunctions in the prefrontal cortex, striatum, and amygdale. Youth with irritability also shows maladaptive orientation to interpreting, and labeling of potential threats, associated with prefrontal cortical and amygdale dysfunction.[36] The current study document the efficacy of intervention program for management of aggression among youth. However, the need is there for higher quality primary studies on the effectiveness of anger and aggression treatment programs using a variety of psychological treatment approaches and assessing them at various period interval of follow-up. The modalities can be evolved for different age groups as well as with comorbid psychological conditions. The study also implies for discussion of anger management techniques in school programs and students should be thought to handle their emotions effectively. The intervention program can also include assertiveness training and enhancement of resilience among youth.

Financial support and sponsorship

This study was financially supported by Indian Council of Social Science Research funded work.

Conflicts of interest

There are no conflicts of interest.