Children and Youth Services Review 33 (2011) 19891993

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Children and Youth Services Review

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h

Cognitive behavioural therapy for violent behaviour in children and adolescents:

A meta-analysis
Nilfer zabac
Eskisehir Osmangazi University Education Faculty Guidance and Counselling, 26480, Meselik, Eskisehir, Turkey

a r t i c l e

i n f o

Article history:
Received 21 March 2011
Received in revised form 16 May 2011
Accepted 16 May 2011
Available online 24 May 2011
Keywords:
Agression
Violence
Cognitive behavioural therapy
Meta analysis

a b s t r a c t
Aggressive behaviours often co-occur with other emotional, behavioural, academic, and social relationship
problems. During adolescence, these children often exhibit increased rates of school dropout, depression,
juvenile delinquency, substance abuse, and poor peer relationships. Some denitions focus on aggression as
an emotion; according to this framework, aggressive behaviours stem from anger. Other denitions
emphasise the motivational aspect of aggression, wherein intentions are thought to indicate the behavioural
characteristics. Cognitivebehavioural therapy (CBT) is one of the most extensively researched forms of
psychotherapy. This paper aims to review the literature on the use of CBT for treating children and adolescents
who demonstrate high levels of violence. Studies were searched for using several methods. First, we used
large database of literature on psychological treatments of violence in general. Studies were traced by means
of several methods. A large database of 240 papers on the psychological treatment of aggression and violence
in general were used. This database was developed through a comprehensive literature search (from 1997 to
March 2009) in which we examined abstracts in ERIC (19 abstracts), Psycinfo (30), and Medline (23).
Keywords used in computer searches were: Aggression, Violence, CBT, cognitivebehavioural therapy,
cognitive therapy, behaviour therapy, and behavioural activation. The options were used in computer
searches so that all relevant topics within the broader categories were searched as well. Six studies met the
inclusion criteria, all of which indicated benecial results of using CBT. A meta-analysis suggested an effect
size of 0.094 for reduced violence as a result of CBT treatment; this is considered to be a medium effect. The
differential effects of cognitivebehavioural therapy and affective education were variable, although they
were also generally in the medium range. In this meta-analytic study, CBT treatment proved less effective in
reducing aggressive behaviour. This review tentatively suggests potential for using CBT to reduce violence in
children and adolescents. However, there is only a small body of research exploring this relationship at
present. Further research is needed before any solid conclusions can be drawn.
2011 Elsevier Ltd. All rights reserved.

1. Introduction
Cognitivebehavioural therapy (CBT) is one of the most extensively researched forms of psychotherapy. The question of whether a
particular psychotherapy is superior to others has produced ardent
controversy. In addition to comparative efcacy, key questions exist
regarding the long-term effectiveness of cognitivebehavioural
therapy (CBT); in other words, to what extent do intervention effects
persist after the cessation of treatment. Related to this is the question
of whether effects resulting from CBT treatments persist to a greater
extent than do those of other treatments (Hollon & Beck, 1994).
Excessive aggression, such as ghting, stealing and victimisation, is
a common childhood problem (Offord, Boyle, Fleming, Munroe, &
Rae-Grant, 1989; Offord & Lipman, 1996), affecting up to 10% of 6- to

Tel.: + 90 2222393750/1633, + 90 5058691910 (GSM).

E-mail address: niluferozabaci@hotmail.com.
0190-7409/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2011.05.027

15-year-olds. Aggressive behaviours often co-occur with other

emotional, behavioural, academic, and social relationship problems.
Moreover, these behaviours tend to aggregate in families (Lahey et al.,
1988). During adolescence, these adolescents often exhibit increased
rates of school dropout, depression, juvenile delinquency, substance
abuse, and poor peer relationships (Campbell, 1991; Loeber, 1991).
Some denitions focus on aggression as an emotion; according to
this framework, aggressive behaviours stem from anger (Moftt,
1993). Other denitions emphasise the motivational aspect of
aggression, wherein intentions are thought to indicate the behavioural characteristics.
Inspection of the DSM-IV disorders applicable to youth reveals
several diagnostic criteria, associated features, and descriptors that
are relevant to anger. Irritability is a prominent feature of all major
mood disorders, including bipolar disorders and depressive disorders.
In adjustment disorders involving disturbance of emotions or
conduct, there often are violation of the rights of others, aggressive
behaviour, and persistent anger (DSM-IV-TR).

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N. zabac / Children and Youth Services Review 33 (2011) 19891993

Aggressiveness, poor impulse control, and intense anger and

hostility are, likewise, characteristics of a broad range of disorders
involving abuse or withdrawal from alcohol or other drugs.
Intermittent explosive disorder is dened primarily by discrete
episodes of loss of control of aggressive behaviour (Sukhodolsky,
Kassinove, & Gorman, 2004).
Numerous variables (e.g., context, parenting, and peer relations)
are known to predict antisocial outcomes in adolescence (Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikstro'm, 2002). Whether
these variables increment the prediction beyond dispositional factors
in early life is still under debate (Dodge, Coie, & Lynam, 2006).
However, given that CBT's focus on modifying thinking and
transferring the skills learned in the therapy to everyday life (i.e.,
making the patient his/her own therapist), treatment effects would be
expected to persist following termination. Indeed, this has indicated
long-term effectiveness of CBT and its relative success at preventing
relapse (Beck, 1995).
Several socialcognitive models have detailed cognitive processes
that may be related to anger and aggression. These models stem from
the original social learning formulations by Bandura (1973) and
causal attribution (Kelley, 1972). The social information processing
model developed by Dodge (1980) postulated a ve-step sequential
model of cognitive processes: encoding of social cues, interpretation
of cues, response search, response decision, and enactment of
behaviour.
Disruption in any of these processes can lead to anger and
aggressive behaviour. Kendal, Ronan & Epps (1991) made a
distinction between cognitive deciencies and cognitive distortions.
Deciencies refer to the absence of thinking, such as not thinking
about the consequences of one's behaviour, and distortions, such as a
hostile attribution bias, which refers to the faulty processing of social
information. Cognitive deciencies require interventions that enrich
the repertoire of cognitive and behavioural skills, whereas cognitive
distortions require modication of already existing cognitive and
behavioural patterns.
Meta-analysis has gained recognition as a useful way to evaluate
treatment efcacy. It has both advantages and limitations relative to
other review methods (Cooper & Hedges, 1994; Wilkinson, 1999).
Hence, the strength of meta-analysis comes from the use of a
standardised unit that allows the comparison of outcomes from
studies that may use different measures. Additionally, by averaging
effect sizes across different studies and comparing them, metaanalyses can be used to increase sample size and minimise the
inuence of extraneous factors. This allows for a more precise
evaluation of treatment efcacy. There were two main objectives in
this meta-analysis: (1) to evaluate the overall effect size of CBT for
violent behaviour in children and adolescents, (2) to explore the
effects of CBT across the domains of outcome measures and the
categories of informants.

behavioural activation. The option was used in computer searches

so that all relevant topics within the broader categories were searched
as well.
Studies were obtained and included if they met the following
criteria:
(a) study participants were selected for a diagnosis of violence
(b) random assignment to treatment conditions was used
(c) at least one of the treatment conditions was identied as a
behavioural, cognitive, or cognitivebehavioural intervention
(the comparison conditions could be either a passive control or
alternate treatment)
(d) sample age range was between 6 and 18 years old
(e) the study was published in an English language, peer-reviewed
journal. Studies had to report post-treatment data (means and
standard deviation) for at least one outcome measure assessing
violence. Studies also had to report data for at least one
cognitive, coping, behavioural, or physiological target at posttreatment. Studies did not have to report data for all four
process categories.
2.1.2. Study coding procedures
The following categories of characteristics were coded for each
outcome study: characteristics of the participants, study design
characteristics, treatment characteristics, therapist experience, and
measurement characteristics. Studies were coded to identify:
(a) sample characteristics
(b) treatment and design characteristics
(c) violence outcome measures used; and treatment outcome
measures were included for effect size coding if they assessed
violent symptoms.
2.2. Characteristics of the participants
Sample characteristics included age (mean age per treatment
condition), gender (percent male per treatment condition) and
severity of aggression or violent behaviour. The severity category
was coded based on presence or absence of repetitive patterns of
aggression and violent behaviour.
2.3. Treatment characteristics

2. Material and methods

Treatment characteristics included the following variables: type of

treatment, format of treatment, treatment duration, and treatment
setting. The type of treatment was coded as follows: 1 = Cognitive
behavioural therapy (CBT); The format of the treatment was coded so
that 1 indicated group therapy and 2 indicated individual therapy.
Treatment duration was coded as number of hours participated in
therapy. Finally, treatment setting was coded as follows: 0 = school,
home, and 3 = clinic (Table 1).

2.1. Research design

2.4. Meta-analysis procedure

2.1.1. Identication and selection of studies

Studies were searched for using several methods. First, we used
large database of literature on psychological treatments of violence in
general. Studies were traced by means of several methods. First, we
used a large database of 240 papers on the psychological treatment of
aggression and violence in general. Sukhodolsky, Kassinove and
Gorman (2004) was searched for papers up until 1997. This database
was developed through a comprehensive literature search (from 1997
to March 2009) in which we examined abstracts in ERIC (19
abstracts), Psycinfo (30), and Medline (23). Keywords used in
computer searches were: Aggression, Violence, CBT, cognitive
behavioural therapy, cognitive therapy, behaviour therapy, and

A meta-analysis was conducted on those outcome measures

reported by all studies. Effect sizes and odds ratios of these variables
were included in the meta-analysis. Effect sizes were estimated from
the standardised mean of the CBT groups. A random effects model
with a 95% condence interval was used for all analyses. The results
were conrmed using the software packages 'MetaAnalyst' .
Cohen (1988) was used as the measure of effect size (ES). Cohen's
d is calculated as the mean difference between the treatment group
mean outcome and the control group mean outcome divided by the
pooled (within-group) standard deviation. All ES values were
corrected for small sample bias (Hedges and Olkin, 1985) and then
the level of treatment. This permitted an evaluation of effect size for

N. zabac / Children and Youth Services Review 33 (2011) 19891993

Table 1
Characteristics of Studies Included in the Meta Analysis.
Characteristics
Year of Publication of Completion
2004
2005
2006
2007
2008
2009
Treatment Type
Cognitive Behavioural Therapy
Treatment modality
Group
Individual
Therapist experience
Professional (PhD, CSW)
Graduate student
Paraprofessional
Treatment Setting
School
Home
Clinic
Correctional Facility

1991

Table 2
Descriptive characteristics of studies evaluating CBT for youth violence.
Number of Studies
1
1
3
1

1
7
3
1
5
1

1
3
3

an average CBT condition. Consistent with previous research, ES

values were then weighted by the inverse of their variance, adjusting
for differing sample sizes and heterogeneity of variance seen across
studies (Hedges and Olkin, 1985).
As a nal step when calculating mean ES values, a Q-statistic was
calculated to test the assumption that all ES values estimated the same
population (i.e., homogeneity in ES distributions). Rejecting homogeneity would indicate that the variability among the effect sizes of
the different studies is greater than what is likely to have resulted
from subject-level sampling error alone. In these cases where
homogeneity was rejected, we adopted a random effects model
which accounts for random variability at both the study-level (studies
sampled from a population of studies) and the subject-level (subjects
in each study sampled from a population of studies). This model uses a
different inverse variance weight than the xed effects model that is
used when effect sizes represent a homogeneous distribution (Wilson
2003).
3. Results
3.1. Intervention summary
Treatments that implemented a full CBT programme showed a
very small and statistically insignicant 0 = school, home, or inpatient
facility and 3 = clinic. Tests of homogeneity using Q-variance nearly
all suggested that the effect size differences were homogenous. The Qvalue of the study was equal to 1.43. In treating violence, when CBT
treatments were compared to other therapy programmes, insignicant heterogeneity was found on indirect measures when combining
all time points. However, this was not true when measuring the nal
(endpoint) outcome only.
The mean effect size of this meta analysis was calculated to be
0.094. This result shows that the effectiveness of CBT among
intervention groups was correlated with the control group. According
to Cohen, this mean effect size value indicates a small effect of CBT in
treating violence in children and adolescents (Table 2).
3.2. Cumulative efcacy of CBT over time
As detailed in Fig. 1, the mean cumulative ES of CBT for violence
among children and adolescents has decreased steadily from the large
effects observed in the earlier trials, With the accumulation of
outcome data for a particular treatment, it could be argued that the

Study

Participants

Treatments

Measure

ES

Van Manen et al.

(2004)
Apsche and Bass
(2006)
Lipman et al. (2006)

n = 82 913 y

SCST, MESSY, TRA,

SCRS, TOPS, TRFC
CBCL, DSMD

0.094

n = 97 711 y

SCIB, SST,
CBT MFFT
MDT, CBT,
SST
CBT

0.240

Granic & Patterson

(2007)
McCart (2006)
Apsche et al. (2005)

n = 27 711 y

PMT, CBT

BCFPI, OCHS, CIA

CBQ, CHI, PSI
PSDT, CAFAS, CBCL

n = 38 1418 y
n = 24 adolsc.

PBT, CBT
MDT, CBT, SS

IAB, BASC-PRS-A
DBR, BIR

0.41
0.06

n = 39 1118 y

0.03

0.25

y: years old, Social Cognitive Intervention Programme: SCIB, Social Skills Training
Program: SST , Ss: session, The Matching Familiar Figures Test: MFFT, Matson Evaluation
of Social Skills with Youngsters: MESSY, The Social Cognitive Skills Test: SCST, Teacher
Ratings of Aggression: TRA, Self-Control Rating Scale: SCRS, Taxonomy of Problematic
Social Situations for Children: TOPS, Teacher Rating Form: TRF, Child Behaviour
Checklist: CBCL, Mode Deactivation Therapy: MDT, Social Skills Training: SST, Devereux
Scales of Mental Disorders: DSMD, Aggression Scale: AS, Brief Chil and Family Phone
Interview: BCFPI, OCHS: Ontario Child Health Study Revised Inventory, CIA: Childrens'
Inventory of Anger, PSDT: Problem Solving Discussion Topic, Child Behaviour
Questionnaire: CBQ, Childrens Hostility Index: CHI, Parenting Stress Index-Short
Form: PSI, The Child and Adolescent Functional Assessment Scale: CAFAS, Child conduct
problems: CBCL, Parent ManagementTraining: PMT, IAB: Interview AntiSocial
Behaviour, BASC-PRS-A: Behaviour Assesment System for Children Parent Rating
Scale Adolescence, IES-R: The Impact of Events Scale Revised, NOBAG-S: Normative
Beliefs About Aggression Scale, SIPA: Stress Index for Parents-Adolescence, BSI: Brief
Symptom Inventory, APQ: Alabama Parenting Questionnaire, Mode Deactivation
Therapy (MDT), Daily Behaviour Reports = DBR, Behaviour Incident Reports = BIR.

cumulative mean ES of treatment should approach the population ES

parameter. There are numerous methodological differences between
the included studies, however, and it is plausible that the decrease in
the effects of CBT is related to these differences (Table 3, Fig. 1).
4. Discussion
Six trials compared the effectiveness of CBT to control groups. The
studies are summarised in Table 2. The fth study demonstrated a
mean effect size of 0.41, which is in the medium range (Cohen, 1988).
The mean effect size of the third study was 0.24; the mean effect size
in the fourth study was 0.25. Study effect sizes in this meta-analysis
ranged from 0.20 to 0.50 overall. These results can be interpreted as
indicating small effectiveness of CBT in treating violence in children
and adolescents (Cohen, 1988). When outcomes were assessed with
directly relevant measures, CBT does not appear to be particularly
efcacious. On indirect measures, the difference favouring CBT was
notably smaller, not reaching statistical signicance in the case of
violence.
The effects of CBT for aggression-related problems in children and
adolescents were investigated using a sample of six (ve published
and one unpublished) outcome studies. Sukhodolsky, Kassinove and
Gorman (2004) analysed a sample of 21 published and 19 unpublished outcome studies published between 1968 and 1997 and found
a mean effect size of 0.67. Butler, Chapman, Forman and Beck (2006)
found a mean effect size of 0.95 in a sample of 16 recent metaanalyses that answered the multifaceted questions: How effective is
CBT, for which disorders, and compared to what? How lasting are
these effects?
This meta-analysis of six studies found a mean effect size of
0.094, which suggests that CBT is only somewhat effective in
treating violence problems in youth. Its effects are comparable with
the effects of psychotherapy with children and adolescents in general.
The four types of CBT grouped according to the target of therapy and
predominant therapeutic techniques (e.g., skills development, Mode
Deactivation Therapy, and eclectic treatments) differed in their
overall effects. These types of CBT can be viewed as varying on a
scale from less behavioural (affective education and problem

1992

N. zabac / Children and Youth Services Review 33 (2011) 19891993

Fig. 1. The cumulative plot of condence interval characteristics of meta analysis studies evaluating CBT for youth violence.

Table 3
Cumulative effect sizes of cognitivebehavioural therapy over time(random effects,
acute treatment stage). Information steps dened by subsequent publications.
Study added

Size of study
added

Est.

95% Condence
Interval

Van Manen et al. (2004)

Apsche and Bass (2006)
Lipman et al. (2006)
Granic & Patterson (2007)
McCart (2006)
Apsche et al. (2005)

82
39
97
27
38
24

0.000
0.000
2.877
2.387
2.002
0.952

28.430
18.264
6.580
5.301
4.872
3.053

28.430
18.264
0.827
0.527
0.867
1.148

solving) to more behavioural (eclectic treatments and skills

development). When taking such groupings into account, these
results suggest that treatments that teach actual behaviours are
more effective than treatments that attempt to modify internal
constructs believed to be related to targeted behaviours. This
interpretation is compatible with the nding that behavioural
interventions yield greater effect sizes than non-behavioural interventions (Casey & Berman, 1985; Weisz et al., 1987, 1995).

5. Conclusions
This review provides a meta-analytic exploration of the use of CBT
for treating violence in children and adolescents. The main strength of
this review lies in the way it uses thorough meta-analytic methodology to explore this issue. Violence in children and adolescents is an
important area of children's health. Despite this, only six studies were
uncovered, which strongly indicates the need for more randomised
control trials in this area. Because of the small number of studies
reviewed, any conclusions regarding the value of CBT for treating
violence in children and adolescents must remain tentative.
In summary, although research is limited, this review suggests that
many children who complete CBT report clinically signicant re-

ductions in violence. This is encouraging and suggests the need for

further research addressing this area.

References
Apsche, J. A., & Bass, C. K. (2006). A review and empirical comparison of three
treatments for adolescent males with conduct and personality disorder: mode
deactivation therapy, cognitive behavior therapy and social skills training.
International Journal of Behavioral Consultation And Therapy, 3(2), 2532.
Apsche, J. A., Bass, C. K., Jennings, J. L., Murphy, C. L., Hunter, L. A., & Siv, M. A. (2005).
Empirical comparison of three treatments for adolescent males with physical and
sexual aggression: mode deactivation therapy, cognitive behavior therapy and social
skills training. International Journal Of Behavioral Consultation And Therapy, 2(1),
140148.
Bandura, A. (1973). Aggression: A social learning analysis. NJ: Englewood Cliffs
Prentice-Hall.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press boys
Eugene OR Castalia Press.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of
cognitive therapy: A review of meta-analyses. Clinical Psychology Review, 26,
1731.
Campbell, S. B. (1991). Longitudinal studies of active and aggressive preschoolers:
ndividual differences in early behaviour and outcome. In D. Cicchetti, & S. L. Toth
(Eds.), Rochester Symposium on Developmental Psychopathology (pp. 5790). Hillsdale, NJ: Lawrence Erlbaum Associates.
Casey, R. J., & Berman, J. S. (1985). The outcome of psychotherapy with children.
Psychological Bulletin, 98, 388400.
Cooper, H. M., & Hedges, L. V. (1994). The handbook of research synthesis. New York:
Russell Sage Foundation.
Dodge, K. A. (1980). Social cognition and children's aggressive behavior. Child
Development, 51, 162170.
Dodge, K. A., Coie, J. D., & Lynam, D. (2006). Aggression and antisocial behavior in youth.
In & W. Damon (Ed.), (6th Ed.). In & N. Eisenberg (Ed.), Handbook of child
psychology, Vol. 3. (pp. 719788): New York: Wiley.
Granic, I., & Patterson, G. R. (2007). Toward a comprehensive model of antisocial
development: a dynamic systems approach. Psychological Review, 113, 101131.
Hedges, L. V., & Olkin, I. (1985). Statistical Methods for Meta-analysis. New York:
Academic Press.
Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitivebehavioral therapies. In A. E.
Bergin, & S. L. Gareld (Eds.), Handbook Of analysis (4th Ed). Psychotherapy and
Behavior Change. (pp. 428466) : Oxford: Oxford University Press.
Kelley, H. H. (1972). Causal schemata and the attribution process. Morristown, NJ:
General Learning Press.

N. zabac / Children and Youth Services Review 33 (2011) 19891993

Kendal, P. C., Ronan, K., & Epps, J. (1991). Aggression in children/adolescents: Cognitive
behavioural treatment perspectives. In D. Pepler, & K. H. Rubin (Eds.), The development
and treatment of childhood aggression (pp. 339360). Hillsdale Nj: Erlbaum.
Lahey, B. B., Piacentini, J. C., McBurnett, K., Stone, P., Hartdagen, S., & Hynd, G. (1988).
Psychopathology in the parents of children with conduct disorder and hyperactivity. Journal of American Acaemy of Chld Adolesence Psychatry, 27, 63170.
Lipman, E. L., Boyle, M. D., Cunnngham, C., Kenny, M., Snderman, C., Duku, E., Brenda
Mlls, C. Y. W., Evans, C. F. T., & Marjore Waymouth, B. A. (2006). Testing
Effectiveness Of A Community-Based Aggression Management Program For
Children 7 To 11 Years Old And Their Families. Journal of American Academy of
Chld Adolesence Psychatry, 45(9), 10851093.
Loeber, R. (1991). Antisocial behaviour more enduring than changeable? Journal of
American Acaemy of Chld Adolesence Psychatry, 30, 393399.
McCart, R. M. (2006). Reducing Violence/Victimization among Assaulted Urban Youth.
An published Doctoral Thesis. USA: The University of Wisconsin-Milwaukee.
Moftt, T. E. (1993). Adolescence-limited and life-coursepersistent antisocial behavior:
A development taxonomy. Psychological Review, 100, 674701.

1993

Offord, D. R., Boyle, M. H., Fleming, J. E., Munroe, B. H., & Rae-Grant, N. I. (1989). Ontario child
health study. Summary of selected results. Canadian Journal of Psychiatry, 34, 483491.
Offord, D. R., & Lipman, E. L. (1996). Emotional and behavioural problems: Frequency by
age, gender, and income level and co-occurrence with other problems. Growing Up
in Canada. National Longitudinal Survey of Children andYouth (pp. 89550). Ottawa:
Statistics Canada.
Stouthamer-Loeber, M., Loeber, R., Wei, E., Farrington, D., & Wikstrom, P. H. (2002).
Risk and promotive effects in the explanation of persistent serious delinquency in
boys. Journal of Consulting and Clinical Psychology, 70, 111123.
Sukhodolsky, D. G., Kassinove, H., & Gorman, B. S. (2004). Cognitivebehavioral therapy
for anger in children and adolescents: A meta-analysis. Aggression and Violent
Behavior, 9, 247269.
Van Manen, T. G., Per, M. A., Prns, J. M., & Emmelkamp, P. M. G. (2004). Reducing
aggressive behavior in boys with a social cognitive group. Aggression and Violent
Behavior, 9, 247269.
Wilkinson, L. (1999). Statistical methods in psychology journals: Guidelines and
explanations. American Psychologist, 54, 594604.