cognitive behavioral problem solving skills training

Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

• What Is Cognitive Behavioral Therapy?
• Find a therapist who practices CBT
• Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
• The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
• The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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Problem-Solving Skills Training (PSST)

About this program.

Target Population: 7 to 14 year olds with behavioral problems, particularly children who struggle to handle disappointments, frustrations, or problems calmly

For children/adolescents ages: 7 – 14

Program Overview

PSST is aimed at decreasing inappropriate or disruptive behavior in children. The program teaches that problem behaviors arise because children lack constructive ways to deal with thoughts and feelings and instead resort to dysfunctional ones. It is designed to help children learn to slow down, stop and think, and generate multiple solutions to any given problem. The program uses a cognitive-behavioral approach to teach techniques in managing thoughts and feelings, and interacting appropriately with others. Specific techniques include modeling, role-playing, positive reinforcement of appropriate behavior, and teaching alternative behaviors. Children are typically given homework to help them practice implementing these skills. Most sessions are individual, but parents may be brought in to observe and to learn how to assist in reinforcing new skills.

Program Goals

The goals of Problem-Solving Skills Training (PSST) are:

• Train the child to think differently about situations and behave differently in diverse situations
• Help the child internalize the problem solving steps so that they are able to use them to evaluate potential solutions to problems occurring outside of therapy
• Learn and generalize problem solving skills and how to apply problem solving skills using self-instruction
• Learn how to generate positive solutions that would enable the child to avoid physical aggression, resolve the conflict, and keep themselves out of trouble

Logic Model

The program representative did not provide information about a Logic Model for Problem-Solving Skills Training (PSST) .

Essential Components

The essential components of Problem-Solving Skills Training (PSST) include:

• Sessions that are fun for children as they play various games and have the opportunity to earn prizes as they learn the following:
• The 5 Problem Solving Steps used to handle any problem situation
• How to use these problem solving steps for hypothetical problems
• How to use these problem solving steps for simple problems outside of session
• How to use these steps to solve challenging hypothetical situations
• How to ultimately use these steps to solve problems that come up in their own life
• Individual treatment with one of the staff of certified clinicians who will keep the child's goals in mind throughout the therapy
• A number of sessions with the parent before beginning with the child so that the parents will know how to encourage and maintain the child's growth

Program Delivery

Child/adolescent services.

Problem-Solving Skills Training (PSST) directly provides services to children/adolescents and addresses the following:

• Oppositional behavior, aggressive behavior, antisocial behavior

Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Parents are involved sporadically during treatment to help support their child in implementing Problem-Solving Skills Training .

Recommended Intensity:

Weekly 50-minute sessions

Recommended Duration:

Approximately 8 to 14 weeks

Delivery Settings

This program is typically conducted in a(n):

• Outpatient Clinic

Problem-Solving Skills Training (PSST) includes a homework component:

The child is given homework to help them learn to apply problem solving skills to everyday situations. Homework is a natural extension of treatment where learned problem solving skills are applied to real life situations.

Resources Needed to Run Program

The typical resources for implementing the program are:

PSST requires a standard clinical treatment room.

Manuals and Training

Prerequisite/minimum provider qualifications.

PSST providers must be Master's level mental health professionals.

Manual Information

There is not a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:

• Bernadette Lecza, MS, CKPMT [email protected]

Training Type/Location:

Training is occasionally available either online or onsite.

Number of days/hours:

Total training time is about 8 hours.

Implementation Information

Pre-implementation materials.

There are no pre-implementation materials to measure organizational or provider readiness for Problem-Solving Skills Training (PSST) .

Formal Support for Implementation

There is no formal support available for implementation of Problem-Solving Skills Training (PSST) .

Fidelity Measures

There are no fidelity measures for Problem-Solving Skills Training (PSST) .

Implementation Guides or Manuals

There are implementation guides or manuals for Problem-Solving Skills Training (PSST) as listed below:

A comprehensive overview of Problem Solving Skills Training is available. For more information, please contact the program representative who is listed at the bottom of the page.

Research on How to Implement the Program

Research has not been conducted on how to implement Problem-Solving Skills Training (PSST) .

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Kazdin, A., Esveldt-Dawson, K., French, N., & Unis, A. (1987). Problem-Solving Skills Training and relationship therapy in the treatment of antisocial child behavior. Journal of Consulting and Clinical Psychology, 55 (1), 76–85. https://doi.org/10.1037/0022-006X.55.1.76

Type of Study: Randomized controlled trial Number of Participants: 56

Population:

• Age — 7–13 years
• Race/Ethnicity — 77% White and 23% Black
• Gender — 45 Male and 11 Female
• Status — Participants were inpatients at a psychiatric facility.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effects of cognitive-behavioral Problem-Solving Skills Training (PSST) and nondirective relationship therapy (RT) for the treatment of antisocial child behavior. Participants were randomly assigned to PSST , relationship therapy (RT), or a control group that had therapist contact with no directed focus on the elements of the two treatment conditions. Measures utilized include the Child Behavior Checklist (CBCL), Therapist Evaluation Inventory, and the Child Evaluation Inventory . Results indicate that children in the PSST condition had greater decreases in aggression, externalizing behaviors, and overall behavior problems and greater increases in pro-social behavior at follow-up than did the RT and control groups. Limitations include the use of a hospitalized sample and reliance on a small number and type of evaluations.

Length of controlled postintervention follow-up: 1 year.

Kazdin, A. E., Bass, D., Siegel, T., & Thomas, C. (1989). Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior. Journal of Consulting and Clinical Psychology, 57 (4), 522–535. https://doi.org/10.1037/0022-006X.57.4.522

Type of Study: Randomized controlled trial Number of Participants: 112

• Race/Ethnicity — Not specified
• Gender — 87 Male and 25 Female
• Status — Participants were children receiving inpatient or outpatient treatment at a child conduct clinic.

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate alternative treatments for children referred for severe antisocial behavior. Participants were randomized to receive one of two Problem-Solving Skills Training (PSST) treatment conditions: standard PSST or PSST-P which included a set of planned activities and "homework" to be performed outside of therapeutic sessions, or to a relationship therapy (RT) control condition. Measures utilized include the Child Behavior Checklist (CBCL), the School Behavior Checklist, the Parent Daily Report, Interview for Antisocial Behavior, the Children's Action Tendency Scale,  and the Self-Esteem Inventory . Results indicate that both PSST groups showed significantly higher improvement in behavior than the RT group. Improvement in PSST-P children's school-related behaviors were shown to be stronger in comparison with standard PSST . Limitations include no direct assessment of the cognitive processes that problem-solving skills training were designed to change and relationship therapy may not have been well or fairly tested.

Kazdin, A. E., Siegel, T. C., & Bass, D. (1992). Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology, 60 (5), 733–747. https://doi.org/10.1037/0022-006X.60.5.733

Type of Study: Randomized controlled trial Number of Participants: 97

• Race/Ethnicity — 69% White and 31% Black
• Gender — 76 Male and 21 Female
• Status — Participants were children referred for treatment to a psychiatric facility.

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effects of Problem-Solving Skills Training (PSST) and parent management training (PMT) on children referred for severe antisocial behavior. Participants were randomly assigned to receive PSST , PMT, or a combination of PSST + PMT. Measures utilized include the Child Behavior Checklist (CBCL), the Teacher Report Form (TRF), the Health Resources Inventory, the Interview for Antisocial Behavior, the Children's Action Tendency Scale, the Self-Report Delinquency Checklist, the Parent Daily Report, the Parenting Stress Index (PSI), the Beck Depression Inventory (BDI) (mothers), and the Family Environment Scale . Results indicate that children in all conditions showed significant improvement at home and school, which was maintained at follow-up. PSST + PMT had the greatest effects on children's aggressive, delinquent, and antisocial behavior; and was also associated with greater improvements in parental stress and depression. Limitations include lack of an untreated comparison group, large attrition rate, and the small sample size.

Bushman, B. B., & Gimpel Peacock, G. (2010). Does teaching problem-solving skills matter? An evaluation of Problem-Solving Skills Training for the treatment of social and behavioral problems in children. Child & Family Behavior Therapy, 32 (2), 103–124. https://doi.org/10.1080/07317101003776449

Type of Study: Randomized controlled trial Number of Participants: 26

• Age — Mean=8.27 years
• Race/Ethnicity — 23 Caucasian, 1 Asian, and 2 Biracial
• Gender — 17 Male and 9 Female
• Status — Participants were families with children with social and behavioral problems.

Location/Institution: Utah

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effectiveness of Problem-Solving Skills Training (PSST) for the treatment of social and behavioral problems in children. Participants were randomly assigned to either a PSST treatment group or a nondirective comparison group. Measures utilized include the Skills Rating System (SSRS), the Parent Daily Report (PDR), Child Behavior Checklist for Ages 6-18 (CBCL/6-18), Parenting Stress Index-Short Form (PSI-SF) , and a parent questionnaire at baseline, post-treatment, and at a 6-week follow-up. Results indicate that children in both the treatment and comparison group showed similar improvement, with PSST showing a minor advantage on several PDR and SSRS scales. Limitations include the small sample size and short-term follow-up.

Length of controlled postintervention follow-up: 6 weeks.

Additional References

Kazdin, A. E. (2010). Problem-Solving Skills Training and Parent Management Training for Oppositional Defiant Disorder and Conduct Disorder. In J. R. Weisz & A. E. Kazdin (Eds.). Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 211-226). Guilford Press.

Kazdin, A. E. (2011). Problem-Solving Skills Training for children and adolescents: Overview. Yale Parenting Center.

Kazdin, A. E. (2017). Parent Management Training and Problem-Solving Skills Training for child and adolescent conduct problems. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp.142–158). Guilford Press.

Contact Information

Date Research Evidence Last Reviewed by CEBC: December 2023

Date Program Content Last Reviewed by Program Staff: November 2021

Date Program Originally Loaded onto CEBC: April 2009

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The CEBC is funded by the California Department of Social Services’ (CDSS’) Office of Child Abuse Prevention and is one of their targeted efforts to improve the lives of children and families served within child welfare system.

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Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that focuses on changing negative thought patterns and behaviors. It is based on the idea that maladaptive behaviors and emotions can be changed by modifying negative thoughts and beliefs.

CBT is typically short-term and goal-oriented, and it has been shown to be effective for a wide range of mental health conditions, including anxiety disorders, depression, and post-traumatic stress disorder (PTSD).

Rational Emotive Behavior Therapy (REBT)

Rational Emotive Behavior Therapy (REBT) was first developed by Dr. Albert Ellis in the 1950s.  It is a type of CBT that focuses on identifying and changing irrational beliefs. The therapy is based on the idea that people’s emotions and behaviors are influenced by their beliefs and thoughts, and that many of these beliefs are irrational and unhelpful.

REBT aims to identify and challenge these unhelpful beliefs and replace them with more rational ones. It has been shown to be effective for a wide range of mental health conditions, including depression, anxiety, and addiction.

Rational Living Therapy (RLT)

Rational Living Therapy (RLT) was first developed by Dr. Aldo Pucci in the 1990’s.  It is another form of CBT that focuses on the here-and-now and the practical application of rational thinking to daily life. It is based on the idea that people can improve their lives by learning to think and act in more rational ways.

RLT is a very systematic approach to cognitive-behavioral therapy that provides structure for each session.

In conclusion, CBT, REBT, and RLT are three effective forms of psychotherapy that focus on changing negative thoughts and beliefs to improve mental health and overall well-being. While each type of therapy has its own unique approach and techniques, they all share a common goal of helping individuals overcome their mental health challenges and achieve their goals.

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About Dr. Aldo R. Pucci

I am president of the National Association of Cognitive-Behavioral Therapists, pastor of Abundant Grace Bible Church, and most importantly, Sandy's husband, Aldo and Maria's dad, Trevor's Pa, and Olivia and Madelyn's grandpa.

2 Comments on “CBT Training”

Do you have any training for CBT clinicians who are using Mandarin Chinese with their clients? All clinicians are skilled practitioners working for a university but asked to do CBT in their mother tongue (Mandarin) but have all done their university training in English.

We are sorry. We only offer trainings in English.

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Cognitive Problem-Solving Skills Training

A cognitive therapy approach.

CPSST aims to decrease a young person’s inappropriate or disruptive behaviors by teaching new, constructive ways to manage thoughts and feelings and interact appropriately with others. CPSST therapy focuses on the child or adolescent (rather than on the parents or family), teaching them skills to develop new perspectives and problem-solve new solutions. 

According to CPSST’s underlying principles, children have problematic behaviors because their ways of interpreting reality and responding to the world are limited and involve negative responses . In this way, CPSST expands the “behavioral repertoire”—the range of ways of behaving that an individual possesses—through cognitive processing. CPSST is effective in treating young people with:

• Conduct disorder (CD)
• Intermittent explosive disorder (IED)
• Oppositional-defiant disorder (ODD)
• Attention-deficit/hyperactivity disorder (ADHD) with disruptive behavior 
• Antisocial behaviors or aggressive acting-out

Research on CPSST

In outcome studies, CPSST has been found to be effective in reducing or eliminating problematic behaviors in many children and adolescents. Its success is even greater when combined with  parent management training . Although CPSST originally focused on children with problem behaviors or poor relationships with others, it has generalized to a variety of different disorders in children, adolescents and adults.

CPSST therapy includes weekly individual sessions with the child or adolescent, for a duration of 3-12 months. Through modeling, role-playing, games, real-life experiments and positive reinforcement, treatment helps them: 

• Think differently, challenge unhelpful assumptions, confront irrational interpretations of others’ actions and change inaccurate or narrow views of situations
• Internalize and apply problem-solving skills to generate alternative, positive solutions and avoid physical aggression, resolve conflict and keep out of trouble 

For example:

• A child, suspended from school for becoming physically aggressive with a teacher, is asked by the clinician to describe his thoughts and feelings about the experience. The child says, “My teacher hates me. She always yells at me.” 
• The clinician helps the child explore supporting evidence to confirm or disconfirm that assumption, so the child can see his part in the problem and ways he can influence better interactions in the future. 

Homework component : The young person is given between-session homework, including keeping a log of negative thoughts, conducting a real-life experiment or trying a new option and comparing results to prior activity. In this way, they learn to apply problem-solving skills when faced with problematic situations in school, with peers or at home. Beginning with the easiest ways of thinking, the young person gradually progresses to more complex or challenging circumstances. 

Parental support : Parents or other family members may be brought in to observe and to learn how to assist in reinforcing new skills . Parents learn how to remind their child to use CPSST problem-solving techniques in daily living, as well as how to provide age-appropriate positive reinforcement for trying new techniques and options through praise, affection or other desirable rewards.  

The aim of therapy is to help a young person change perceptions and develop different options for how to respond in difficult situations. Gradually, they shift from making global, negative attributions—“It’s someone else’s fault,” perhaps—to identifying ways to improve a specific outcome. Ultimately, the child or teen gains a sense of efficacy in achieving reliably more positive outcomes in future situations.

Learn more about Cognitive Therapies offered at CFI…

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• Provide Psychosocial Skills Training and Cognitive Behavioral Interventions

What to Know

Psychosocial skills training and cognitive behavioral interventions teach specific skills to students to help them cope with challenging situations, set goals, understand their thoughts, and change behaviors using problem-solving strategies.

Psychosocial skills training asks students to explore whether their behaviors align with their personal values. Cognitive behavioral interventions teach students to identify their own unhelpful thoughts and replace them with thoughts that are more helpful. Students might practice helpful coping behaviors and find positive activities to try. Doing these things can improve their mood and other symptoms of mental distress.

Districts and schools can deliver interventions in one-on-one settings, small groups, and classrooms. Some interventions focus on concepts that are also taught in social skill and emotional development programs, like self-control and decision-making. A counselor or therapist can lead these programs.

What Can Schools Do?

Promote acceptance and commitment to change.

Schools can help promote acceptance and positive behavior change for students through psychosocial skills training and dialectical behavior therapy. Psychosocial skills training asks students to explore whether their behaviors align with their personal values. Students who see that their behavior does not match their values can decide to make behavior changes. These trainings also help students accept what they cannot change and focus on what they can change. Dialectical behavior therapy teaches mindfulness, acceptance, and commitment skills.

Approaches using acceptance and commitment to change are associated with increases in students’ coping skills and decreases in depression and physical symptoms of depression.

Provide Cognitive Behavioral Interventions

Cognitive behavioral interventions for schools often include multiple sessions. They can be used for one student or a small group. Sessions often follow a standardized manual of activities to help students examine their own thoughts and behaviors. The interventions can include asking students to share what they learn about their thoughts and behaviors with their parents and other people. In some interventions, session leaders focus on a specific topic. Other interventions target mental health symptoms, like depression, anxiety, or post-traumatic stress.

Cognitive behavioral interventions can improve students’ mental health in many ways, including decreasing anxiety, depression, and symptoms related to post-traumatic stress.

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Engage Students in Coping Skills Training Groups

Coping skills training groups use principles of cognitive behavioral intervention to teach students skills to help them handle specific problems. Students can also use these skills to help them cope when their lives are changing. Similar to social, emotional, and behavioral learning programs, coping skills training often focuses on building resilience, or being able to “bounce back” when bad things happen. Students can practice skills outside of the small group, like they would with social skills and emotional development lessons.

Coping skills training groups can increase coping skills for students and decrease anxiety and depression.

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Focus on Equity

Students who have been exposed to trauma may receive trauma-focused or trauma-informed interventions in school. Cognitive behavioral interventions that are trauma-informed meet the unique needs of students exposed to traumatic experiences. These interventions teach problem-solving and relaxation techniques and help reduce trauma-related symptoms, including behavioral challenges. Trauma-informed interventions can also improve students’ coping strategies.

Implementation Tips

Cognitive behavioral interventions and psychosocial skills training help with many kinds of student needs. They can be used at multiple grade levels. Leaders can:

• Work with school mental health staff to find ways for students to practice their new behaviors and coping skills.
• Use the Multitiered Systems of Support (MTSS) framework to ensure that students are appropriately matched with classroom, small-group, or individual interventions that meet their needs.

Want to Learn More?

For more details on MTSS and providing psychosocial skills training and cognitive behavioral interventions, see Promoting Mental Health and Well-Being in Schools: An Action Guide for School Administrators [PDF - 3 MB]

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• Introduction
• Conclusions
• Article Information

GRADE indicates Grading of Recommendations, Assessment, Development, and Evaluations; SMD, standardized mean difference.

a For meta-analysis of parental problem-solving skills, quality of life, pediatric quality of life, and social functioning, the problem-solving skills training (PSST) group was preferable when the effect size was greater than 0, while the value of effect size for other outcomes less than 0 indicated a favor of PSST.

b For meta-analysis of parental posttraumatic stress, quality of life, pediatric mental problems, and parent-child conflict, the values of I 2 were less than 50%, and the inverse variance method was therefore used.

c Downgraded 1 level for serious inconsistency due to statistical heterogeneity.

d Downgraded 1 level for serious risk of bias of included studies.

e Downgraded 1 level for serious inconsistency due to statistical heterogeneity, and downgraded 1 level for serious imprecision due to limited sample size.

f Downgraded 1 level for serious inconsistency due to statistical heterogeneity, and downgraded 2 levels for very serious imprecision due to limited sample size and wide CIs.

g Downgraded 2 levels for very serious imprecision due to limited sample size and data from only 2 studies.

h Downgraded 1 level for serious inconsistency due to statistical heterogeneity and downgraded 1 level for serious imprecision due to wide CIs.

i Downgraded 1 level for serious imprecision due to limited sample size.

j Downgraded 1 level for serious risk of bias of included studies and downgraded 1 level for serious imprecision due to limited sample size.

eTable 1. Study Search Strategies

eTable 2. Intervention Characteristics of Included Studies

eTable 3. Author Judgments of Risk of Bias Across All Included Studies

eTable 4. Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Profile

eFigure 1. Forest Plot Meta-Analyses for Different Psychosocial Outcomes

eFigure 2. Subgroup Analyses of Each Outcome According to Children- and Intervention-Level Factors

eFigure 3. Funnel Plot Analyses

eFigure 4. Leave-One-Out Sensitivity Analyses

Data Sharing Statement

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Zhou T , Luo Y , Xiong W , Meng Z , Zhang H , Zhang J. Problem-Solving Skills Training for Parents of Children With Chronic Health Conditions : A Systematic Review and Meta-Analysis . JAMA Pediatr. 2024;178(3):226–236. doi:10.1001/jamapediatrics.2023.5753

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Problem-Solving Skills Training for Parents of Children With Chronic Health Conditions : A Systematic Review and Meta-Analysis

• 1 Xiangya School of Nursing, Central South University, Changsha, Hunan, China
• 2 Xiangya Hospital, Central South University, Changsha, Hunan, China

Question   What is the association between problem-solving skills training (PSST) for parents of children with chronic health conditions and psychosocial outcomes of the parents, their children, and their families?

Findings   In this systematic review and meta-analysis of 23 randomized clinical trials including 3141 parents, PSST was associated with improvements in parental problem-solving skills; decreased parental depression, distress, posttraumatic stress, and parenting stress; better quality of life for both parents and children; fewer pediatric mental problems; and less parent-child conflict.

Meaning   These findings suggest that PSST should be an active component of and serve as an emerging perspective for psychosocial interventions for parents of children with chronic health conditions.

Importance   Problem-solving skills training (PSST) has a demonstrated potential to improve psychosocial well-being for parents of children with chronic health conditions (CHCs), but such evidence has not been fully systematically synthesized.

Objective   To evaluate the associations of PSST with parental, pediatric, and family psychosocial outcomes.

Data Sources   Six English-language databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library), 3 Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang), gray literature, and references were searched from inception to April 30, 2023.

Study Selection   Randomized clinical trials (RCTs) that performed PSST for parents of children with CHCs and reported at least 1 parental, pediatric, or family psychosocial outcome were included.

Data Extraction and Synthesis   Study selection, data extraction, and quality assessment were conducted independently by 2 reviewers. Data were pooled for meta-analysis using the standardized mean difference (SMD) by the inverse variance method or a random-effects model. Subgroup analyses of children- and intervention-level characteristics were conducted.

Main Outcomes and Measures   The psychosocial outcomes of the parents, their children, and their families, such as problem-solving skills, negative affectivity, quality of life (QOL), and family adaptation.

Results   The systematic review included 23 RCTs involving 3141 parents, and 21 of these trials were eligible for meta-analysis. There was a significant association between PSST and improvements in parental outcomes, including problem-solving skills (SMD, 0.43; 95% CI, 0.27-0.58), depression (SMD, −0.45; 95% CI, −0.66 to −0.23), distress (SMD, −0.61; 95% CI, −0.81 to −0.40), posttraumatic stress (SMD −0.39; 95% CI, −0.48 to −0.31), parenting stress (SMD, −0.62; 95% CI, −1.05 to −0.19), and QOL (SMD, 0.45; 95% CI, 0.15-0.74). For children, PSST was associated with better QOL (SMD, 0.76; 95% CI, 0.04-1.47) and fewer mental problems (SMD, −0.51; 95% CI, −0.68 to −0.34), as well as with less parent-child conflict (SMD, −0.38; 95% CI, −0.60 to −0.16). Subgroup analysis showed that PSST was more efficient for parents of children aged 10 years or younger or who were newly diagnosed with a CHC. Significant improvements in most outcomes were associated with PSST delivered online.

Conclusions and Relevance   These findings suggest that PSST for parents of children with CHCs may improve the psychosocial well-being of the parents, their children, and their families. Further high-quality RCTs with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence.

Childhood chronic health conditions (CHCs) include physical, developmental, behavioral, or emotional conditions with an expected duration of more than 3 months or the impossibility of cure. 1 Approximately 37% of children have at least 1 current or lifelong health condition. 2 The diagnosis of a childhood CHC and its prolonged treatments are profoundly unsettling experiences for children and their families, especially their parents. 3 - 5 Compared with parents of healthy children, parents of children with CHCs have reported worse mental health (more depression, anxiety, and posttraumatic stress), 6 - 8 significant stress and burden, 9 , 10 and a poorer quality of life (QOL). 6 , 11 Considering that parental psychosocial outcomes are strongly associated with children’s health and family adaptation, 12 - 14 interventions to improve parents’ well-being may have synergistic benefits for the whole family. Parental problem-solving skills, which are associated with parents’ well-being, are general coping skills applicable to a variety of difficult situations commonly encountered during the treatment of childhood CHCs. 15 With better problem-solving skills, parents could become more self-assured to address children’s health concerns, fully use resources to cope with stress, and collaborate to address challenges presented by daily care, thereby improving family adaptation and children’s health outcomes. 16 However, nearly one-half of parents lack problem-solving skills, especially the ability to solve daily problems related to their children’s complex treatment processes, 3 which may eventually perpetuate negative outcomes for parental and child well-being. 17 , 18

Problem-solving skills training (PSST) is an effective intervention to improve problem-solving skills and decrease negative affectivity. 19 , 20 Based on the problem-solving therapy approaches of D’Zurilla and colleagues, 20 , 21 PSST includes 2 essential components: establishing a positive problem orientation and mastering the systematic steps to solve problems. The training has long been established as being effective in adults with chronic illness and their caregivers, 22 , 23 which theoretically could have broad outcomes for parents of children with CHCs due to the long-term nature and equally multiple, intensive, and ongoing stressors across childhood CHCs. Problem-solving skills training is a cognitive-behavioral process by which parents can identify and create problem-focused strategies to buffer the outcomes of stressful events and improve coping, thus preventing episodes of negative affectivity by effectively solving various children’s disease-related problems. 15 , 21 These problem-solving strategies, while possibly differing in specifics, are beneficial in helping parents to cope with significant stressors inherent to each CHC. Preliminary studies have shown the efficacy of PSST in enhancing problem-solving skills and alleviating depression symptoms for parents, although the majority of such studies have had small sample sizes. Moreover, these studies only considered improved parental well-being, and most did not show significant changes in pediatric or family adaptation outcomes. 15 , 24 In addition, although previous reviews of PSST have explored the effectiveness of psychosocial interventions for parents of children with CHCs, they had limited specificity. 19 , 25 - 28 To address these gaps, we evaluated the associations between PSST for parents of children with CHCs and parental, pediatric, and family psychosocial outcomes.

The study protocol for this systematic review and meta-analysis has been registered with PROSPERO ( CRD42023424077 ). The revised Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA ) guideline 29 was followed to report the findings.

A systematic search was performed across 6 English-language databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library) and 3 Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang) from inception to April 30, 2023. The search strategies applied a combination of Medical Subject Heading terms and keywords, and the following constructs were used: child AND chronic health conditions AND parents AND PSST. The full search string for each database is provided in eTable 1 in Supplement 1 . Gray literature was searched using OpenGrey, Mednar, and the World Health Organization’s search portal. We also screened reference lists of included studies to identify potentially eligible articles.

The population, intervention, comparator, outcomes, and study design framework was used to define the inclusion and exclusion criteria ( Table 1 ). Eligible studies were RCTs that performed PSST for parents of children with CHCs and reported at least 1 psychosocial outcome of parents, children, or their families.

All identified articles were imported into EndNote, version 20.0 (Clarivate Analytics) to eliminate duplications. Title and abstract screening and full-text review were performed independently using the web-based software Rayyan 30 by 2 reviewers (T.Z. and W.X.). Data extraction was conducted in duplicate by the 2 reviewers and checked by another reviewer (Y.L.). Information was extracted using a predesigned worksheet, including publication details, population demographics (pediatric [age, medical condition, and illness duration] and parental [age, sex, race and ethnicity]), intervention and control group details (approach, mode, number of sessions, and duration), and psychosocial outcomes and measures.

We included only the postintervention data in the meta-analysis, as follow-up data were not reported consistently enough to achieve proper homogeneity. When both parents and children reported a psychosocial outcome of children, we prioritized extracting the parent-reported data, as they were more reliable. If multiple records were available for the same trial, we collected all relevant data and analyzed them as a single study. Corresponding authors were contacted via email to retrieve missing data.

The risk of bias for the included studies was assessed independently by 2 reviewers (T.Z. and W.X.) according to the revised Cochrane risk-of-bias tool, version 2.0, 31 which includes 5 domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. We judged the studies to be low risk, of some concern, or high risk. Additionally, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) 32 framework was applied to assess the certainty of the evidence for all outcomes. The certainty was categorized as high, moderate, low, or very low based on the risk of bias, inconsistency, imprecision, indirectness, and publication bias. 33 , 34 Any disagreements in the study selection, data extraction, and quality assessment processes were resolved through discussion to reach a consensus, and if conflicts persisted, they were arbitrated by a third reviewer (Y.L.).

Statistical analyses were performed using Stata, version 16 software (StataCorp LLC). We conducted a meta-analysis only when 2 or more intervention studies were available with similar participants and outcomes. The psychosocial outcomes included in this review were measured by different scales; therefore, the effect size is presented as the standardized mean difference (SMD) with 95% CI. 35 Statistical heterogeneity was assessed using both the χ 2 test and I 2 statistic. 36 The inverse variance method ( P  ≥ .10 and I 2 <50%) or a random-effects model ( P  < .10 or I 2 ≥50%) was applied based on the P and I 2 values. Subgroup analyses were performed for children’s and intervention characteristics. In addition, we conducted leave-one-out sensitivity analyses to examine the consistent associations between PSST and all identified outcomes. We also used funnel plots and Egger test to evaluate the publication bias for analyses with at least 10 studies. 37 The threshold for statistical significance was set at a 2-sided P  < .05. The most recent analysis update was performed between October 10 and 20, 2023.

The initial comprehensive search yielded 2665 publications: 2641 from 9 databases and an additional 24 from gray literature and reference list review. After removing 1195 duplicates and screening 1470 titles and abstracts, 227 full-text articles were assessed for eligibility. Ultimately, 23 eligible RCTs 38 - 60 were included in the review, and 21 studies 38 - 42 , 44 - 48 , 50 - 60 were included in the meta-analysis ( Figure 1 ). Almost perfect agreement on the study selection was achieved (97%; κ = 0.89). 61

Table 2 summarizes the characteristics of the included 23 RCTs published between 2002 and 2021. Most were conducted in the US (21 studies 38 , 40 - 44 , 46 - 60 ), with 1 study each in Australia 45 and Jamaica. 39 Twenty-one studies 38 - 48 , 50 - 59 used a 2-arm RCT design. In addition, most studies (12 [52%]) 39 , 42 , 45 - 48 , 50 , 53 - 57 reported that a control group received usual care.

A total of 3141 parents were included in this review. Twenty-one studies 38 - 47 , 49 - 58 , 60 reported on parent sex, which totaled 2799 mothers (94%) and 185 fathers (6%), and 6 studies 38 , 39 , 42 , 53 - 55 only recruited mothers. The age of the parents ranged from 20 to 67 years, with an estimated mean (SD) age of 38.3 (9.0) years. Of 2914 parents who reported race and ethnicity, 38 , 41 - 44 , 46 - 60 569 (19%) were Hispanic, 316 (11%) were non-Hispanic Black, 1708 (59%) were non-Hispanic White, and 321 (11%) were of other race or ethnicity. The CHC diagnoses were traumatic brain injury (6 studies), 49 , 51 , 57 - 60 cancer (5 studies), 38 , 52 - 55 sickle cell disease (2 studies), 39 , 40 autism spectrum disorder (2 studies), 41 , 42 epilepsy (2 studies), 46 , 47 mental health problems (1 study), 43 inflammatory bowel disease (1 study), 44 first-episode psychosis (1 study), 45 diabetes (1 study), 48 chronic pain (1 study), 50 and asthma (1 study). 56 The mean (SD) age of the children was 10.0 (5.5) years, with the illness duration ranging from 2 weeks to 8 years.

Problem-solving skills training was confirmed as the primary focus of the intervention across the 23 RCTs, all of which were developed based on problem-solving therapy that emphasized positive problem orientation and covered the 5 core problem-solving steps (eTable 2 in Supplement 1 ). The number of PSST sessions included ranged from 2 to 21, with the duration of PSST varying from 5 weeks to 12 months. Most studies (18 [78%]) 38 - 43 , 45 - 48 , 50 , 52 - 57 , 60 involved interventions that required parents to attend face-to-face sessions, 6 of which integrated telephone-based online support. 40 , 43 , 45 - 48 In the remaining studies, 38 , 44 , 49 , 51 , 52 , 58 - 60 PSST was delivered entirely online, including via telephone sessions, web-based didactic modules, and videoconferences. Three interventions 39 - 41 were group-based, 9 interventions 38 , 42 , 43 , 45 , 50 , 52 - 55 were delivered to individuals 1 on 1, and 11 interventions 44 , 46 - 49 , 51 , 56 - 60 included both parents and children.

The methodological quality assessment resulted in 96% mutual agreement (κ = 0.93). 61 Seven studies (30%) 39 , 42 , 45 , 47 , 50 , 51 , 56 were classified as low risk, 8 studies (35%) 40 , 44 , 46 , 52 , 55 , 57 , 58 , 60 raised some concerns, and 8 studies (35%) 38 , 41 , 43 , 48 , 49 , 53 , 54 , 59 were identified as having a high risk ( Figure 2 ). Two studies 41 , 48 reported neither random sequence generation nor allocation concealment and hence were considered high risk for the randomization process. For 5 trials (22%), 38 , 49 , 53 , 54 , 59 there was a high risk of reporting bias, as the prespecified outcomes were not fully reported (eTable 3 in Supplement 1 ).

Figure 3 illustrates the meta-analysis summary for all outcomes. Forest plots and GRADE ratings are presented in eFigure 1 and eTable 4 in Supplement 1 , respectively.

Overall, PSST had a significant positive effect on problem-solving skills (12 studies including 1887 parents 38 - 42 , 46 , 50 , 52 - 55 , 58 ; SMD, 0.43; 95% CI, 0.27-0.58; I 2  = 64.28%), depression (12 studies including 2036 parents 38 , 39 , 41 , 42 , 50 - 52 , 54 , 55 , 57 , 58 , 60 ; SMD, −0.45; 95% CI, −0.66 to −0.23; I 2  = 85.29%), and distress (12 studies including 2038 parents 38 , 45 , 50 - 55 , 57 - 60 ; SMD, −0.61; 95% CI, −0.81 to −0.40; I 2  = 83.88%), all of which indicated a medium effect size and moderate certainty evidence. The studies also showed that PSST significantly alleviated posttraumatic stress (5 studies including 1469 parents 38 , 50 , 52 , 54 , 55 ; SMD, −0.39; 95% CI, −0.48 to −0.31; I 2  = 44.93%) and parenting stress (5 studies including 391 parents 39 , 41 , 42 , 45 , 50 ; SMD, −0.62; 95% CI, −1.05 to −0.19; I 2  = 76.24%). The levels of evidence for the associations of PSST with lower posttraumatic stress and parenting stress were moderate and low, respectively. The meta-analysis of parental anxiety showed a positive but nonsignificant effect. In addition, 2 studies 45 , 50 including 175 parents indicated a significant improvement in QOL among parents in the PSST group (SMD, 0.45; 95% CI, 0.15-0.74; I 2  = 0.00%), with low-certainty evidence and no heterogeneity ( Figure 3 ).

There was an association between PSST and better pediatric QOL compared with control groups (6 studies including 590 parents 40 , 44 , 47 , 48 , 56 , 60 ; SMD, 0.76; 95% CI, 0.04-1.47; I 2  = 94.90%). Data for 436 parents showed a significant association between PSST and fewer children’s mental problems (6 studies 50 , 51 , 57 - 60 ; SMD −0.51; 95% CI, −0.68 to −0.34; I 2  = 34.54%) ( Figure 3 ). We found that PSST had both medium effect sizes for improving pediatric QOL and mental health, with low- and moderate-certainty evidence, respectively, whereas no association was found for social functioning. Four RCTs 41 , 48 , 51 , 57 including 314 parents provided low-certainty evidence that PSST may reduce parent-child conflict (SMD, −0.38; 95% CI, −0.60 to −0.16), with moderate heterogeneity ( I 2  = 36.98%).

Subgroup analyses were conducted according to child- and intervention-level characteristics (eFigure 2 in Supplement 1 ). Subgroup analysis by child age indicated that PSST was associated with significant changes in parental depression (SMD, −0.39; 95% CI, −0.52 to −0.26), problem-solving skills (SMD, 0.36; 95% CI, 0.24-0.48), posttraumatic stress (SMD, −0.40; 95% CI, −0.49 to −0.31), and parenting stress (SMD, −0.43; 95% CI, −0.72 to −0.13) for the parents of children who were 10 years or younger compared with the parents of older children (>10 years). Regarding changes in parental depression and posttraumatic stress, PSST had no association for parents of children who had not been newly diagnosed with a CHC but was associated with significant changes (reductions) for parents of children with newly diagnosed CHCs (depression: SMD, −0.40 [95% CI, −0.52 to −0.28]; posttraumatic stress: SMD, −0.40 [95% CI, −0.49 to −0.31]). Furthermore, compared with other medical conditions, PSST was associated with significant improvement in all psychosocial outcomes in parents of children diagnosed with cancer.

Overall, PSST delivered online yielded larger effects on all outcomes except for parent-child conflict than only face-to-face PSST. There was a significant improvement in depression (SMD, −0.39; 95% CI, −0.52 to −0.27) and problem-solving skills (SMD, 0.37; 95% CI, 0.24-0.50) among parents who received individual-based PSST. However, the parent-child interventions showed significant changes in pediatric and family psychosocial outcomes. As for intervention duration, PSST for 5 to 8 weeks had stronger effects on reducing parental depression and parenting stress and improving problem-solving skills than PSST with durations exceeding 8 weeks. The number of sessions followed a similar pattern, with significant improvements in depression (SMD, −0.48; 95% CI, −0.67 to −0.28) and problem-solving skills (SMD, 0.50; 95% CI, 0.29-0.70) among parents who underwent 8 to 12 sessions.

We assessed the publication bias for outcomes that included more than 10 trials (problem-solving skills, parental depression, and distress). Overall, the funnel plots were mostly symmetrical (eFigure 3 in Supplement 1 ); Egger tests were not significant for problem-solving skills ( z  = 1.64, P  = .10), depression ( z  = −1.21, P  = .23), and distress ( z  = −0.46, P  = .65), thus indicating no publication bias. The leave-one-out sensitivity analyses yielded similar results to those of the primary analyses, indicating the robustness of key outcomes (eFigure 4 in Supplement 1 ).

This systematic review and meta-analysis of 23 RCTs is the first to our knowledge to adequately examine the positive association of PSST with improved parental, pediatric, and family psychosocial outcomes. The findings show that PSST was associated with improved problem-solving skills, less negative affectivity, and better QOL for parents. Positivity and problem-solving throughout PSST is achieved by refining problems and effectively troubleshooting obstacles commonly encountered during the treatment of childhood CHCs, thus contributing to parental well-being. 15 , 41 Additionally, PSST was associated with improvements in pediatric QOL, mental health, and parent-child conflict, in accordance with previous review results that psychological interventions for parents may facilitate their ability to scaffold behavioral and emotional changes in their children and thus reduce conflicts between parents and children. 19 , 27 , 62 Our findings extend this evidence by suggesting that PSST is also associated with better psychosocial outcomes for children and families, showing promise for the use of PSST to increase the well-being of all family members and promote family adaptation.

Problem-solving skills training is an emerging and promising area of research, with 17 (74%) included studies published in 2010 or later. 39 - 47 , 49 - 52 , 55 , 56 , 59 , 60 A total of 3141 patients were included in this review, and there were sufficient sample sizes for most outcomes. Although the included RCTs were conducted in only 3 countries, which may decrease the representativeness of the results in terms of dissemination capability, the ethnic and linguistic diversity of parents across included studies showed equally positive responses to PSST when presented in various contexts. Across all psychosocial outcomes, the certainty of the evidence varied from moderate to very low. Despite the suggested effectiveness of PSST in this review, some heterogeneity remains. On one hand, the included studies used diverse definitions and instruments to measure psychosocial outcomes; on the other hand, the studies included parents of children with 11 different CHCs, all of which may have introduced clinical heterogeneity. However, the diversity may also suggest a better clinical fitness of the evidence in this review. Additionally, the current evidence on the long-term effects of PSST is limited by the small number of follow-up studies. Overall, although our review provides relatively high certainty of evidence, further research on higher-level evidence with sustained follow-up is warranted. Furthermore, it is necessary to expand the range of outcomes (eg, physical and clinical) to fully reflect the effectiveness of PSST, as most relevant studies have only reported psychosocial outcomes.

Our subgroup analysis revealed a significant decrease in negative affectivity among the parents of children aged 10 years or younger and who had been newly diagnosed with CHCs, as younger children are more reliant on their parents for daily life and disease management. 63 These findings are compatible with broader evidence supporting early PSST’s improvement of parental well-being when children are newly diagnosed. 64 A significant decrease in negative emotions was also found among parents of children with cancer compared with the parents of children with other medical conditions, possibly because cancer is a leading cause of death in children 65 and their parents may experience a substantial care burden. 8 , 66 The subgroup analysis according to intervention characteristics indicated that online intervention yielded larger effects on most outcomes than the in-person approach, which may be due to the flexibility and wider dissemination of an online approach. 52 , 67 With the rapid development of internet and mobile technologies in pediatric nursing, 68 future research could combine in-person PSST with enhanced online materials. Additionally, individual-based PSST was preferable for parental well-being, whereas the parent-child intervention favored pediatric and family psychosocial outcomes. The participants had more opportunities to receive personalized feedback in the individual-based interventions that included 1-on-1 activities 69 and to enhance family communication and cohesion in the parent-child intervention. 26 Hence, it may be worthwhile to integrate parent-child interaction when tailoring PSST according to families’ needs. Finally, PSST delivered for 5 to 8 weeks and consisting of 8 to 12 sessions had stronger associations in terms of parental psychosocial outcomes. This finding highlights the importance of shorter periods and less complexity to higher engagement in PSST, as parents’ busy schedules may interfere with long-term interventions. 70

This review had several limitations. First, we limited our search to articles in English and Chinese, which might have led to selection bias and affected the reliability of the results. Second, some of the findings must be interpreted with caution, as they were based on only 2 or 3 studies. Third, the assessment could differ across people due to the methodological subjectivity of the risk-of-bias tool and GRADE. Fourth, the psychosocial outcomes identified in this review were measured using multiple scales, and despite using SMD as recommended, the heterogeneity of most outcomes was high. Hence, the interpretability and application of the results were diminished. Finally, only the postintervention data were analyzed, as follow-up data were not reported consistently and sufficiently, and the long-term outcomes remain unclear.

The findings of this systematic review and meta-analysis suggest that PSST is associated with improvements in parental psychosocial outcomes (problem-solving skills, depression, distress, posttraumatic stress, parenting stress, and QOL) as well as pediatric (QOL and mental problems) and family psychosocial outcomes (parent-child conflict). Moreover, our findings on children- and intervention-level characteristics may guide the design and delivery of future PSST by presenting information on factors associated with effectiveness. Further high-quality RCTs with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence for PSST. In conclusion, PSST should be an active component of psychosocial interventions for parents of children with CHCs.

Accepted for Publication: October 25, 2023.

Published Online: January 2, 2024. doi:10.1001/jamapediatrics.2023.5753

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Zhou T et al. JAMA Pediatrics .

Corresponding Author: Yuanhui Luo, PhD, Xiangya School of Nursing, Central South University, No. 172, Tongzipo Rd, Changsha City 410013, Hunan Province, China ( [email protected] ).

Author Contributions: Drs Zhou and Luo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhou, Luo, J. Zhang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zhou, Luo, H. Zhang.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Zhou, Xiong, Meng, H. Zhang.

Obtained funding: Luo.

Administrative, technical, or material support: Luo, J. Zhang.

Supervision: Luo, J. Zhang.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant CMB-OC-22-462 from the China Medical Board (Dr Luo).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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CBT Coping Skills and Strategies

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

How CBT Works

Diaphragmatic breathing, progressive muscle relaxation, self-monitoring, behavioral activation, listing pros and cons, cognitive restructuring, setting and managing goals.

CBT coping skills involve dealing with negative emotions in a healthy way. They provide strategies for getting through difficult situations with less tension, anxiety, depression , and stress.

CBT coping skills help you deal with uncomfortable emotions (anxiety, depression, etc.) so you can feel better physically, make better decisions, and more. These cognitive strategies are especially beneficial for individuals with certain mental health conditions, such as by helping reduce symptoms in people with post-traumatic stress disorder (PTSD).

Before discussing specific cognitive coping strategies, it's important to first understand how CBT works. This gives some insight into how the various CBT coping skills can help relieve anxiety, sadness, and other distressing emotions.

Tom M Johnson / Blend Images / Getty Images

Cognitive behavioral therapy (CBT) is based on the idea that psychological problems arise as a result of the way in which we interpret or evaluate situations, thoughts, and feelings. When these interpretations and evaluations are negative, it can lead to unhealthy behaviors.

CBT works by changing unhealthy behavioral patterns by changing the interpretations that lead to them. It also teaches you the skills and cognitive strategies needed to better cope with whatever life throws your way. Here are a few CBT coping skills that have this result.

Diaphragmatic breathing, also called breathing retraining or deep breathing , is a basic cognitive coping strategy for managing anxiety. It is a simple technique but can be very powerful.

Diaphragmatic breathing involves pulling your diaphragm down while taking a deep breath in. You should see your abdominal area rise with each breath, which is why it is sometimes referred to as "belly breathing."

Relaxation exercises can be an effective way to reduce your stress and anxiety. One such exercise is called progressive muscle relaxation (PMR) and involves alternating between tensing and relaxing different muscle groups throughout the body.

With PMR, complete muscle relaxation is obtained by first going to the other extreme (that is, by tensing your muscles). In addition, by tensing your muscles—a common anxiety symptom —and immediately relaxing them, over time, the symptom of muscle tension may become a signal to relax.

Self-monitoring is another basic CBT coping skill. To a large extent, is at the core of all the cognitive-behavioral coping strategies described here.

In order to address a problem or a symptom, we need to first become aware of it. Self-monitoring can help with this. With this awareness, we can then take action to regulate our behaviors so we have more positive outcomes.

When people feel depressed or anxious, they may be less likely to do the things they enjoy. Therefore, it is important to learn how to be more active. Behavioral activation is a CBT coping skill that helps with this.

The goal of behavioral activation is simple. Get more active in areas of your life that you find pleasurable and enjoyable. Being more involved with and engaged in these experiences works by improving your mood.

When faced with a decision, we can sometimes feel paralyzed or trapped. If this occurs, we may not know the best choice.

One way to move forward in situations such as this is to weigh the short- and long-term pros and cons of a situation. This cognitive coping strategy can help us identify the best path to take—that is, a path that is associated with less risk and is consistent with our goals and priorities.

Cognitive restructuring is a common CBT coping skill. How we evaluate and think about ourselves, other people, and events can have a major impact on our mood. This cognitive strategy focuses on identifying negative thoughts or evaluations and modifying them.

Cognitive restructuring involves gathering evidence about certain thoughts, recognizing how they may be misinterpreted or distorted, then replacing them with more positive affirmations. By modifying our thoughts, we can improve mood and make better choices with regard to our behaviors.

Goals (or things that you want to accomplish in the future) can give your life purpose and direction, as well as motivate healthy behaviors focused on improving your life. However, they can also be very overwhelming and a source of stress. Because of this, you want to be careful when setting goals .

This CBT coping skill involves approaching your goals in a way that improves your mood and quality of life as opposed to increasing distress. This could be by setting smaller goals versus bigger ones, for instance, or breaking larger goals down into more manageable chunks.

A Word From Verywell

CBT coping skills can help you better handle and manage difficult emotions and situations. They work by changing how you interpret feelings and events. You can use CBT coping skills for anxiety, stress , depression, and more—providing some much-needed relief.

Frequently Asked Questions

CBT coping skills teach you how to better deal with difficult situations, such as how to relax your body (so your mind can also relax), also changing how you look at circumstances and events so you have more positivity. These processes use the same types of strategies like those used in cognitive behavioral therapy (CBT).

Regularly practicing cognitive coping strategies such as these can help improve your skills. It can also be beneficial to work with a mental health professional as they can focus directly on improving your CBT coping skills in the therapy session. Taking care of your physical health, such as through a healthy diet and exercise, can also help improve your cognitive health.

CBT coping skills such as cognitive restructuring can help change thought patterns that lead to anxiety. Other skills, like diaphragmatic breathing and progressive muscle relaxation, help relax your body when in an anxious state, thereby reducing your feelings of anxiousness.

American Psychological Association. Cognitive behavioral therapy (CBT) .

Fenn K, Byrne M. The key principles of cognitive behavioural therapy . InnovAiT. 2013;6(9):579-585. doi:10.1177/1755738012471029

Ma X, Yue ZQ, Gong ZQ, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults .  Front Psychol . 2017;8:874. doi:10.3389/fpsyg.2017.00874

Safi SZ. A fresh look at the potential mechanisms of progressive muscle relaxation therapy on depression in female patients with multiple sclerosis .  Iran J Psychiatry Behav Sci . 2015;9(1):e340. doi:10.17795/ijpbs340

Hirano M, Ogura K, Kitahara M, Sakamoto D, Shimoyama H. Designing behavioral self-regulation application for preventive personal mental healthcare .  Health Psychol Open . 2017;4(1):2055102917707185. doi:10.1177/2055102917707185

Hirayama T, Ogawa Y, Yanai Y, Suzuki SI, Shimizu K. Behavioral activation therapy for depression and anxiety in cancer patients: a case series study .  Biopsychosoc Med . 2019;13:9.doi:10.1186/s13030-019-0151-6

National Institute on Aging. Cognitive health and older adults .

By Matthew Tull, PhD Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.

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Common Cognitive Behavioral Therapy (CBT) Techniques

Cognitive-behavioral therapy (CBT) is a talk therapy commonly used to treat mental health disorders such as depression, anxiety, and post-traumatic stress disorder. CBT is based on the idea that our thoughts, behaviors, and emotions are interconnected and that we can improve our mental health and well-being by changing negative thought patterns and behaviors. 

There are common techniques used in CBT that individuals can incorporate into their lives. Some techniques are cognitive restructuring, behavioral activitation, exposure therapy, relaxation techniques, social skills training, problem-solving skills, and mindfulness meditation. In this article, we will cover these common cognitive behavior therapy techniques.

Common CBT Techniques

Cognitive restructuring

Cognitive restructuring is commonly used in cognitive-behavioral therapy (CBT) to help individuals identify and challenge negative thought patterns, or "cognitive distortions," that contribute to negative emotions and behaviors. The cognitive restructuring aims to help individuals develop more positive and realistic thought patterns, which can improve mental health and well-being. Here's how cognitive restructuring works in CBT:

• Identify negative thoughts: The first step in cognitive restructuring is identifying negative thoughts or beliefs contributing to negative emotions and behaviors. The person may identify ideas that might include thoughts like "I'm a failure," "I'm not good enough," or "Nobody likes me."
• Challenge cognitive distortions: Once negative thoughts have been identified, the next step is to challenge them using evidence and logic. This step involves asking questions like "Is this thought true?" "What evidence do I have to support this thought?" and "Is there a more balanced way to think about this situation?"
• Develop alternative thoughts: Once cognitive distortions have been challenged, the goal is to develop more positive and realistic alternative thoughts. This step might involve reframing negative thoughts in a more positive light or developing new thoughts that are more accurate and balanced.
• Practice new thoughts: Finally, practicing new thoughts and reinforcing positive thought patterns over time is important. This practice might involve repeating positive affirmations, journaling, or practicing mindfulness techniques.

Cognitive restructuring can be particularly effective for individuals with depression, anxiety, and other mental health disorders. By challenging negative thought patterns and developing more positive and realistic ones, individuals can improve their mood, reduce anxiety, and create greater resilience in difficult situations. Working with a qualified CBT therapist can help individuals learn and practice cognitive restructuring in a supportive and effective way.

Behavioral activation

Behavioral activation is a technique used in cognitive-behavioral therapy (CBT) to help individuals increase their engagement in positive activities that can improve mood and reduce negative emotions. Behavioral activation aims to help individuals identify and engage in meaningful and rewarding activities, which can lead to increased feelings of accomplishment, enjoyment, and satisfaction. Here's how behavioral activation works in CBT:

• Identify and prioritize goals: The first step in behavioral activation is identifying and prioritizing goals important to the individual. This prioritization might include spending time with family and friends, engaging in hobbies and interests, or pursuing career aspirations.
• Identify potential barriers: Once goals have been identified, the next step is identifying potential barriers to achieving those goals. This barrier might include a lack of motivation, low self-esteem, or environmental obstacles.
• Develop a plan of action: Once goals and barriers have been identified, the next step is to develop a plan for achieving those goals. This action might involve breaking goals down into smaller, more manageable steps and developing strategies for overcoming obstacles.
• Track progress and adjust as needed: Finally, tracking progress over time and adjusting the plan as required is essential. This step might involve celebrating successes, reflecting on challenges, and developing new strategies for achieving goals.

Behavioral activation can be particularly effective for individuals with depression, as it can help to increase engagement in positive activities that can improve mood and reduce feelings of hopelessness and despair. It can also be helpful for individuals with anxiety, as it can help to increase feelings of mastery and control over one's environment. Working with a qualified CBT therapist can help individuals learn and practice behavioral activation in a supportive and effective way.

Exposure therapy

Exposure therapy is used in cognitive-behavioral therapy (CBT) to help individuals confront and overcome their fears and anxieties. Exposure therapy aims to help individuals gradually become desensitized to feared stimuli or situations, leading to decreased anxiety and increased coping skills. Here's how exposure therapy works in CBT:

• Identify feared stimuli or situations: The first step in exposure therapy is to identify the specific stimuli or situations that cause anxiety or fear for the individual. This step might include things like public speaking, heights, or spiders.
• Develop a hierarchy of exposure: Once feared stimuli or situations have been identified, the next step is to develop a hierarchy of exposure, ranking the stimuli or situations in order of least to most anxiety-provoking.
• Begin with the slightest anxiety-provoking stimuli: The individual is then gradually exposed to the slightest anxiety-provoking stimuli, using techniques like guided imagery, role-playing, or visualization.
• Increase exposure over time: As the individual becomes more comfortable with the slightest anxiety-provoking stimuli, exposure gradually increases to more anxiety-provoking stimuli, continuing until the individual can confront the most feared stimuli or situations without experiencing debilitating anxiety.
• Practice coping skills: Throughout exposure therapy, the individual also practices coping skills to manage anxiety, such as deep breathing, relaxation techniques, or cognitive restructuring.

Exposure therapy can be particularly effective for individuals with anxiety disorders, phobias, and post-traumatic stress disorder (PTSD). Individuals can develop confidence, resilience, and coping skills by gradually confronting and overcoming fears and anxieties. Working with a qualified CBT therapist can help individuals learn and practice exposure therapy in a safe and supportive way.

Relaxation techniques

Relaxation techniques are vital to cognitive-behavioral therapy (CBT) for anxiety, depression, and other mental health conditions. The goal of relaxation techniques in CBT is to help individuals reduce physical and emotional tension, promote calmness and relaxation, and increase coping skills. Here are some standard relaxation techniques used in CBT:

• Deep breathing: Deep breathing exercises involve slow, controlled inhalation and exhalation, focusing on the sensations of the breath. This technique can help to reduce physical tension and promote relaxation.
• Progressive muscle relaxation: Progressive muscle relaxation involves tensing and releasing different muscle groups throughout the body, promoting physical relaxation and awareness of bodily sensations.
• Visualization: Visualization techniques involve imagining a calming or peaceful scene, such as a beach or forest, and focusing on the sights, sounds, and sensations associated with that scene.
• Mindfulness meditation: Mindfulness meditation involves focusing on the present moment, observing thoughts and feelings without judgment, and practicing non-reactivity.
• Yoga and stretching: Yoga and stretching exercises can help reduce physical tension, promote relaxation, and improve flexibility and mobility.

Relaxation techniques can be particularly effective when combined with other CBT techniques, such as cognitive restructuring and exposure therapy. By learning and practicing relaxation techniques, individuals can develop greater control over their physical and emotional responses to stress and anxiety, leading to improved mental health and well-being. Working with a qualified CBT therapist can help individuals learn and practice relaxation techniques in a safe and supportive way.

Social skills training

Social skills training is used in cognitive-behavioral therapy (CBT) to help individuals improve their interpersonal communication and relationships. The goal of social skills training in CBT is to teach individuals specific skills and strategies for effective communication, assertiveness, and conflict resolution. Here's how social skills training works in CBT:

• Identify areas for improvement: The first step in social skills training is to identify the specific areas where the individual could benefit from improvement. This step might include initiating conversations, expressing emotions, or handling conflict.
• Teach specific skills: Once areas for improvement have been identified, the individual is taught specific skills and strategies for improving communication and relationships. This skill includes active listening, assertiveness, and nonviolent communication.
• Role-play and practice: Social skills training often involves role-playing and practice, allowing the individual to practice new skills in a safe and supportive environment. This practice might include practicing initiating conversations, giving and receiving feedback, or handling conflict.
• Generalization and maintenance: As individuals become more comfortable with new social skills, they are encouraged to generalize them to real-world situations and maintain their progress over time.

Social skills training can be convenient for individuals with social anxiety disorder, depression, or other mental health conditions that impact social functioning. By learning and practicing specific skills and strategies, individuals can develop greater confidence, assertiveness, and interpersonal effectiveness, leading to improved mental health and well-being. Working with a qualified CBT therapist can help individuals learn and practice social skills training in a safe and supportive way.

Problem-solving skills

Problem-solving skills training is used in cognitive-behavioral therapy (CBT) to help individuals learn effective problem-solving strategies and improve their ability to manage challenging situations. The goal of problem-solving skills training in CBT is to teach individuals a structured approach to problem-solving that can be applied to various situations. Here's how problem-solving skills training works in CBT:

• Identify the problem: The first step in problem-solving skills training is to identify the specific problem or challenge that the individual is facing. This identification might involve brainstorming different options and considering the pros and cons of each.
• Generate possible solutions: Once the problem has been identified, the individual is encouraged to generate as many possible solutions as possible. This solution might involve thinking creatively and considering a range of different options, even if some of them seem unlikely or unrealistic.
• Evaluate the options: Once a range of possible solutions has been generated, the individual is encouraged to evaluate each option based on its potential effectiveness, feasibility, and consequences. This option might involve considering the costs and benefits of each option, as well as the potential risks and rewards.
• Select the best option: Based on the evaluation process, the individual is encouraged to select the best option for addressing the problem or challenge. This option might involve considering the potential outcomes of each option and selecting the one most likely to lead to a positive effect.
• Implement and evaluate: Once a solution has been selected, the individual is encouraged to implement it and evaluate its effectiveness over time. This step might involve monitoring progress and making adjustments as needed based on feedback and results.

Problem-solving skills training can be convenient for individuals with anxiety, depression, or other mental health conditions that impact problem-solving abilities. By learning and practicing effective problem-solving strategies, individuals can develop greater confidence and resilience in facing challenges, leading to improved mental health and well-being. Working with a qualified CBT therapist can help individuals learn and practice problem-solving skills training in a safe and supportive way.

Mindfulness meditation

Mindfulness meditation is used in cognitive-behavioral therapy (CBT) to help individuals develop greater self-awareness and improve their ability to regulate their thoughts, emotions, and behaviors. Mindfulness meditation in CBT aims to teach individuals to focus on the present moment without judgment or distraction. Here's how mindfulness meditation works in CBT:

• Establish a mindfulness practice: The first step in mindfulness meditation is to establish a regular mindfulness practice, which might involve sitting quietly for a few minutes each day and focusing on the breath, body sensations, or other present-moment experiences.
• Develop self-awareness: As individuals begin to practice mindfulness meditation regularly, they develop greater self-awareness, which can help them recognize patterns of thought, emotion, and behavior that might contribute to mental health challenges.
• Cultivate acceptance: As individuals become self-aware, they also learn to cultivate acceptance and non-judgmental awareness, allowing them to observe their thoughts and emotions without getting caught up in them or reacting impulsively.
• Apply mindfulness to daily life: As mindfulness meditation becomes integrated into everyday life, individuals can apply mindfulness techniques to various situations, including stressful or challenging experiences. This application might focus on the breath, body sensations, or other present-moment experiences to help regulate emotions and behaviors.

Mindfulness meditation can be particularly effective for individuals with anxiety, depression, or other mental health conditions that impact emotion regulation and self-awareness. By learning and practicing mindfulness meditation techniques, individuals can develop greater resilience and coping skills, leading to improved mental health and well-being. Working with a qualified CBT therapist can help individuals learn and practice mindfulness meditation in a safe and supportive way.

CBT techniques can be highly effective in helping individuals improve their mental health and well-being and can be tailored to their specific needs and circumstances. Working with a qualified CBT therapist can help individuals learn and practice these techniques in a supportive and effective way.

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* Please  note that the purpose of consultation training and fidelity ratings are to improve provider skills, adherence to the CBSST model and overcome implementation barriers. Consultation is not for treatment planning or advice about the care of any individual clients.  The treatment of clients at the agency is entirely the responsibility of the agency and providers at the agency.

Clinician Qualifications:   No specific credentials are required to deliver CBSST, but clinicians must be able to work with consumers with serious mental illness and be hopeful and supportive of their living, learning, working and socializing recovery goals. Example of CBSST Implementation Timeline: Phase I (3 months): Preparation and CBSST Workshop Training a. Planning meeting with administrators who make a commitment to integrate CBSST b. Identify CBSST Team leader(s) and clinical staff who will initially deliver CBSST and participate in 2-day workshop c. 2-Day CBSST training workshop including information and practical experiential learning exercises (role plays; video demonstrations) Phase II (6 months): CBSST Skills Development a. CBSST team leader advocates for implementation of CBSST and schedules and conducts weekly CBSST group consultation together with outside expert CBSST consultant b. Providers practice CBSST with limited caseload and protected supervision time c. CBSST team leader communicates with leadership about obstacles to implementation of CBSST d. CBSST team leader observes CBSST providers in sessions at least once every month and provides feedback in supervision to improve fidelity (use of standardized fidelity rating scales can facilitate this process) Phase III (ongoing): Consolidation and Sustained Practice a. Focus on strengthening CBSST skills in weekly supervision by local CBSST team leader as outside expert CBSST consultant phases out b. CBSST team leader observes clinicians in sessions at least once every 6 months c. Consider starting CBSST alumni group of consumers who can act as role models and peer coaches/providers in groups and in the community CBSST Supervision 1.Supervision Goals   a. Monitor and track CBSST delivery:     i. Module/Session #     ii. At-Home Practice     iii. Goal Progress     iv. Consumer’s level of participation and key thoughts   b. Learn and practice skills (role plays)   c. Evaluate and improve competence and CBSST fidelity at the facility (feedback fidelity ratings)     d. Support clinicians implementing CBSST   e. Brainstorm and problem-solve about obstacles to CBSST implementation   2. Supervision Structure:   a. Recommend weekly 1-hour protected time for group supervision to ensure fidelity and support sustainability   b. Structured agenda to guide meetings (attached):     i. Initial focus on recruiting consumers       ii. Ongoing focus on clinician competence and CBSST fidelity     iii. Initially lead by outside consultant; then by in-house CBSST team leader

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Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents

Objective: Anger, irritability, and aggression are among the most common reasons for child mental health referrals. This review is focused on two forms of behavioral interventions for these behavioral problems: Parent management training (PMT) and cognitive-behavioral therapy (CBT).

Methods: First, we provide an overview of anger/irritability and aggression as the treatment targets of behavioral interventions, followed by a discussion of the general principles and techniques of these treatment modalities. Then we discuss our current work concerning the transdiagnostic approach to CBT for anger, irritability, and aggression.

Results: PMT is aimed at improving aversive patterns of family interactions that engender children's disruptive behavior. CBT targets deficits in emotion regulation and social problem-solving that are associated with aggressive behavior. Both forms of treatment have received extensive support in randomized controlled trials. Given that anger/irritability and aggressive behavior are common in children with a variety of psychiatric diagnoses, a transdiagnostic approach to CBT for anger and aggression is described in detail.

Conclusions: PMT and CBT have been well studied in randomized controlled trials in children with disruptive behavior disorders, and studies of transdiagnostic approaches to CBT for anger and aggression are currently underway. More work is needed to develop treatments for other types of aggressive behavior (e.g., relational aggression) that have been relatively neglected in clinical research. The role of callous-unemotional traits in response to behavioral interventions and treatment of irritability in children with anxiety and mood disorders also warrants further investigation.

Introduction

C hildhood disruptive behaviors such as anger outbursts and aggression are among the most frequent reasons for outpatient mental health referrals. In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anger/irritability is the core symptom of oppositional defiant disorder (ODD), and aggressive behavior is most commonly associated with conduct disorder (CD) (American Psychiatric Association 2013 ). However, children with other psychiatric disorders are also at increased risk of anger and aggression, and disruptive behavior disorders are often comorbid with other forms of psychopathology. For example, in population-based studies, the prevalence rates of disruptive behavior disorders range from 14% to 35% in children with attention-deficit/hyperactivity disorder (ADHD), from 14% to 62% in children with anxiety disorders, and from 9% to 45% in children with mood disorders (Nock et al. 2007 ). This review is focused on psychosocial interventions for anger/irritability and aggression as dimensions of child psychopathology. Specifically, we include parent management training (PMT) and cognitive-behavioral therapy (CBT), because these modalities have received extensive empirical support as stand-alone interventions that are provided in the format of outpatient psychotherapy (Sukhodolsky et al. 2004 ; Dretzke et al. 2009 ). There is also evidence that these behavioral interventions can be helpful in conjunction with medication management for severe aggression (Aman et al. 2014 ) and as part of multimodal interventions for serious conduct problems, which address multiple risk factors (Sukhodolsky and Ruchkin 2006 ). First, we provide an overview of anger/irritability and aggression as the treatment targets of behavioral interventions, followed by a discussion of the general principles and techniques of these treatment modalities. Then we discuss our current work concerning the transdiagnostic approach to CBT for anger, irritability, and aggression.

Anger, Irritability, and Aggression as Treatment Targets of Behavioral Interventions

Anger is a negative affective state that may include increased physiological arousal, thoughts of blame, and an increased predisposition toward aggressive behavior (Berkowitz and Harmon-Jones 2004). Anger is often triggered by frustration or interpersonal provocation. It can also vary in duration from minutes to hours and range in intensity from mild annoyance to rage and fury. Factor-analytical studies distinguish between anger experience (i.e., the inner feeling), and anger expression (i.e., an individual's tendency to show anger outwardly, suppress it, or actively cope with it by deploying adaptive anger control skills) (Spielberger 1988 ). Improving anger control skills is a primary focus of child-directed CBT approaches that teach skills for coping with anger and frustration that are part of a broader repertoire of emotion regulation strategies.

From the developmental standpoint, various aspects of the experience and expression of anger emerge at different times and follow different developmental trajectories. Temper tantrums that include crying, stomping, pushing, hitting, and kicking are common in 1–4-year-old children and range in frequency from 5 to 9 times per week with an average duration of 5–10 minutes (Potegal et al. 2003 ). The intensity and number of tantrums tend to decrease with age, although typically developing children continue to outwardly display anger and frustration, behaviors that parents often label as tantrums. This decrease in the frequency of temper tantrums as children age is paralleled by the development of emotion regulation skills and the acquisition of socially appropriate ways to express anger (Blanchard-Fields and Coats 2008). Intense and out-of-control anger outbursts may be of clinical concern in young children (Wakschlag et al. 2010 ). Intense anger outbursts in response to trivial provocations may also persist across development and manifest across various psychiatric disorders. Because of an apparent lack of control, these behaviors have been referred to as “rage attacks” in severe mood dysregulation (Carlson 2007 ) and Tourette Syndrome (TS) (Budman et al. 2003 ) as well as “meltdowns” in children on the autism spectrum (Samson et al. 2015 ).

Over the past decade, factor-analytical studies of ODD symptoms have identified a unique dimension of irritability defined by three symptoms: Often loses temper, easily annoyed, and often angry and resentful (Stringaris and Goodman 2009 ; Burke et al. 2014 ). As a result, the symptoms of ODD are now grouped into three types: Angry/irritable mood, argumentativeness/defiant behavior, and vindictiveness, which highlights both the emotional and behavioral aspects of this disorder. Longitudinal studies have shown that irritability symptoms in childhood are associated with mood and anxiety disorders later in life, whereas defiance and vindictiveness predict later conduct problems (Whelan et al. 2013 ). Growing recognition of irritability in childhood psychopathology (Leibenluft and Stoddard 2013 ) and research on severe mood dysregulation (Leibenluft 2011 ) have led to adding a new diagnostic category in the DSM-5, disruptive mood dysregulation disorder (DMDD) (American Psychiatric Association 2013 ). The core symptoms of DMDD include frequent temper outbursts (i.e., three or more times per week) and irritable or depressed mood between the temper outbursts lasting for most of the day nearly every day. Temper outburst may be manifested as verbal rages and/or physical aggression toward people and property.

Aggression can be defined as an overt behavior that can result in harm to self or others (Connor 2002 ). Several subtypes of aggression (e.g., impulsive, reactive, hostile, affective) have been described based on the presence of an angry affect and contrasted with instrumental, proactive, or planned types of aggression that are not “fueled” by anger (Vitiello and Stoff 1997 ). Another well-known classification distinguishes between overtly confrontational antisocial behaviors, such as arguing and fighting, and covert antisocial behaviors, such as lying, stealing, and breaking rules (Frick et al. 1993 ). Physical aggression was found to be a significant risk factor for conduct disorder at an early age of onset, later violence, and other mental health problems such as ADHD and anxiety (Loeber et al. 2000 ). Compared with physical aggression, nonaggressive antisocial behavior was shown to follow a different developmental trajectory (Nagin and Tremblay 1999 ) and predict later nonviolent criminal offenses (Kjelsberg 2002 ).

Principles and Efficacy of PMT

The causal pathways to childhood anger/irritability and aggressive behavior involve multiple interacting biological, environmental, and psychosocial risk factors (Loeber et al. 2009 ). PMT aims to ameliorate patterns of family interactions that produce antecedents and consequences of maintaining tantrums, aggression, and noncompliance. PMT techniques stem from the fundamental principle of operant conditioning, which states that the likelihood of behavior to recur is increased or weakened based on the events that follow the behavior (Skinner 1938 ). For example, a child is more likely to have another tantrum if previous anger outbursts have resulted in an escape from parental demands or the continuation of a preferred activity. Behaviors such as noncompliance, whining, or bickering may also be reinforced if the same benefits are afforded to the child (Patterson et al. 1989 ).

Harsh and inconsistent discipline such as excessive scolding and corporal punishment have also been shown to increase aggressive behaviors (Gershoff 2002 ). The broad goals of PMT are to reduce the child's aggression and noncompliance by improving parental competence in dealing with these maladaptive behaviors. During PMT, parents are taught to identify the function of maladaptive behavior, to give praise for appropriate behavior, to communicate directions effectively, to ignore maladaptive attention-seeking behavior, and to use consistent consequences for disruptive behaviors. PMT is conducted with parents, although for some approaches, children are invited to facilitate the practice of new parenting skills (Eyberg et al. 2008 ). The efficacy and effectiveness of PMT have been evaluated in >100 randomized controlled studies (Dretzke et al. 2009 ; Michelson et al. 2013 ) and excellent treatment manuals are available for clinicians (Kazdin 2005 ; Barkley 2013). There is evidence that the improvements in child behavior are stable over time and can prevent antisocial behavior in adulthood (Scott et al. 2014 ).

The relative efficacy of different parent training approaches have not been well studied in randomized controlled studies, but meta-analytic reviews suggest that program components associated with larger effects include increased positive parent–child interactions and emotional communication skills, parental consistency with consequences, and in vivo practice of new skills with parents (Wyatt Kaminski et al. 2008 ). Improving parent–child communication about emotions has become a focus of emotion coaching interventions, which teach parents the importance of acknowledging and accepting their children's emotional experiences as well as modeling for their children how to identify, label, and cope with strong emotions (Ramsden and Hubbard 2002 ). A recent study of emotion coaching for parents of preschool children found improvements in children's emotional knowledge and reductions in behavior problems (Havighurst et al. 2010 ). However, adding an emotion coaching component to the already established Positive Parenting Program (Triple-P) did not show additive effects in reducing disruptive behavior (Salmon et al. 2014 ).

Other developments in parent-directed interventions have included adaptations of PMT for children with specific neurodevelopmental disorders. Our work has shown that PMT could be helpful for disruptive behavior in children with TS (Scahill et al. 2006 ) and in children with obsessive compulsive disorder (OCD) (Sukhodolsky et al. 2013 ). Modifications of PMT for these clinical populations required careful consideration of anger outbursts in the context of symptoms manifesting from the primary disorder. For example, irritability and noncompliance could be associated with OCD-related fears or failure of parents to provide accommodations for compulsive behaviors (Storch et al. 2012 ). In children with tics, disruptive behaviors have to be disentangled from complex tics that might resemble purposeful behavior (Sukhodolsky and Scahill 2007 ). More recently, the Research Units on Behavioral Intervention (RUBI) Autism Network has developed and tested a parent training program for irritability and noncompliance in young children with autism (Bearss et al. 2015 ). In addition to standard PMT strategies, the parent training for children on the autism spectrum contains extensive functional assessment strategies, visual schedules for daily routines, and instructions to parents on how to teach developmentally appropriate and adaptive skills to their children.

Child-Directed CBT Approaches

CBT targets deficits in emotion regulation and social problem-solving skills that are associated with aggressive behavior (Dodge 2003). The label “cognitive-behavioral” is used to refer to interventions that are conducted with the child and have an emphasis on the learning principles and the use of structured strategies to produce changes in thinking, feeling, and behavior (Kendall 2006 ). Common cognitive-behavioral techniques include identifying the antecedents and consequences of aggressive behavior, learning strategies for recognizing and regulating anger expression, problem-solving and cognitive restructuring techniques, and modeling and rehearsing socially appropriate behaviors that can replace angry and aggressive reactions. Although CBT is conducted with the child, parents have multiple roles in treatment, including bringing their child to therapy, providing information about their child's behavioral problems, and creating an environment between sessions that is conducive to their child practicing CBT skills. Importantly, parents are asked to recognize their child's effort when applying emotion regulation and problem-solving skills learned in CBT to anger-provoking situations and to provide praise and rewards for behavioral improvements.

Various cognitive-behavioral approaches place relative emphasis on at least one of three content areas: Regulation of excessive anger, learning social problem-solving strategies, and/or developing social skills alternative to aggressive behaviors. Anger control training (ACT) aims to improve emotion regulation and social-cognitive deficits in aggressive children. Children are taught to monitor their emotional arousal and to use techniques such as cognitive reappraisal and relaxation for modulating elevated levels of anger. As part of the training, children also practice socially appropriate responses to anger-provoking situations such as being teased by peers or reprimanded by adults. Several programs of research have evaluated versions of ACT with children (Lochman et al. 2003 ), adolescents (Feindler and Ecton 1986; Deffenbacher et al. 1996 ), and young adults (Kassinove and Tafrate 2002 ). Problem-solving skills training (PSST) addresses cognitive processes, such as faulty perceptions and decision making that are involved in social interaction. For example, hostile attribution bias or inability to generate alternative solutions may contribute to aggressive behavior. Originating from research on social information processing (Dodge et al. 1990 ) and problem solving in children (Shure and Spivack 1972 ), hundreds of studies have examined the association between cognitions in social situations and aggressive behavior (Dodge 2003 ). Participants of PSST are taught to analyze interpersonal conflicts, to develop nonaggressive solutions, and to think about the consequences of their actions in problematic situations. The efficacy of PSST has been demonstrated in several controlled studies (Guerra and Slaby 1990 ; Kazdin et al. 1992 ; Hudley and Graham 1993 ). There is initial evidence that the effects of PSST on conduct problems may be mediated by a change in the targeted deficits in social information processing (Sukhodolsky et al. 2005 ). Social skills training (SST) approaches to reducing aggression and developing assertive behavior are rooted in social-learning theory (Bandura 1973 ). Aggressive youth have been shown to have weak verbal skills, poor conflict resolution skills, and deficits in skills that facilitate friendships (Deater-Deckard 2001 ). The goal of SST with aggressive youth is to enhance social behaviors that can be deployed instead of aggression, as well as behaviors that can be used to develop friendships with nondelinquent peers. Meta-analytic reviews report moderate effects of SST on disruptive behavior (Losel and Beelmann 2003 ) and SST is often used as part of multicomponent interventions such as aggression replacement training (Gundersen and Svartdal 2006 ).

Transdiagnostic Approach to CBT for Anger/Irritability and Aggression

Our approach to CBT for childhood anger and aggression has emerged over the course of three randomized controlled trials (Sukhodolsky and Scahill 2012). The first study evaluated CBT in 33 elementary school children referred by teachers for aggressive behavior in the school setting (Sukhodolsky et al. 2000 ). Compared with the no-treatment control condition, children who received CBT displayed a reduction in teacher reports of aggression and improvement in self-reported anger control. The second study utilized a dismantling design to investigate the relative effectiveness of the social skills training and problem-solving training components of CBT in 26 children referred by their parents for high levels of aggressive behavior (Sukhodolsky et al. 2005 ). Children in both conditions showed a reduction in aggression, whereas the problem-solving condition resulted in a greater reduction in hostile attribution bias, and the skills-training condition resulted in a greater improvement in anger control skills. We also evaluated CBT for explosive anger outbursts and aggression in adolescents with TS (Sukhodolsky et al. 2009 ). TS is characterized by chronic motor and phonic tics that co-occur with disruptive behavior in up to 80% of referred cases (Sukhodolsky et al. 2003 ). We conducted the first randomized study of CBT for anger control versus treatment as usual in 26 adolescents with TS and disruptive behavior. Assessments, which included evaluations by a blinded rater, parent reports, and child self-reports, were conducted before and after treatment as well as 3 months posttreatment. All randomized subjects completed the endpoint evaluation. The parent rating of disruptive behavior decreased by 52% in the CBT condition compared with a decrease of 11% in the control condition. The independent evaluator who was unaware of treatment assignment rated 9 of 13 subjects (69%) in the CBT condition as much improved or very much improved as compared with 2 of 13 (15%) subjects improved in the control condition. The CBT treatment manual that has been developed in these clinical studies has been recently published by Guilford Press (Sukhodolsky and Scahill 2012). Our team is currently conducting a large randomized trial of efficacy and neural mechanisms of CBT for aggression versus a supportive psychotherapy control condition in children across diagnostic categories, which has been funded in response to the Research Domain Criteria (RDoC) initiative. The design of this study is described in our companion article of this issue (Sukhodolsky at al. 2016 this issue).

The treatment starts with a detailed assessment of the frequency (i.e., number of episodes per week), duration (i.e., time) and intensity (i.e., risk of injury, property damage, and impact on family) of anger outbursts and aggressive behaviors. Aggression is operationalized as instances of verbal threats, physical aggression, property damage, and self-injury (Silver and Yudofsky 1991 ). Based on a structured clinical interview with the parent(s) and the child, two to three of the most pressing behavioral problems are identified as target symptoms, and used to tailor therapeutic techniques as outlined in the treatment manual (Sukhodolsky and Scahill 2012 ). The treatment is organized into three modules: Emotion regulation, social problem-solving, and the development of social skills for preventing and resolving conflict situations. The first module starts with identifying anger triggers, developing prevention strategies, and learning emotion regulation skills such as cognitive reappraisal and relaxation training. Sessions 4–6 cover problem-solving skills such as the generation of multiple solutions and the consideration of consequences for different courses of action in conflicts. Sessions 7–9 focus on developing skills for preventing or resolving potentially anger-provoking situations with friends, siblings, parents, and teachers. For example, participants are asked to recall a situation in which they acted aggressively and to role-play behaviors that would have prevented the enactment of aggressive behaviors. Each session consists of a menu of therapeutic techniques and activities that can be use used in a flexible yet reliable manner in order to achieve session goals. Each child session also includes a parent component in which parents are informed about the skills that their child has learned in the session, and a plan is devised that enables the practicing of these skills before the next session. Parents are asked to serve as coaches to facilitate the acquisition of new skills by rewarding nonaggressive behaviors with praise, attention, and privileges. Three separate parent sessions are provided to identify patterns of aversive family interactions that might initiate or maintain a child's aggressive behavior. Parents are then given instruction on how to pay attention to their child's positive behavior and to provide consistent reinforcement for their child's efforts in tolerating frustration and using cognitive problem-solving strategies. Additional parenting strategies discussed in treatment include giving effective commands, ignoring minor misbehaviors, and setting up behavioral contracts.

Although excellent treatment manuals are available in the area of child and adolescent anger control (Feindler and Ecton 1986 ; Lochman et al. 2008 ), most are written in a group therapy format for use in school or inpatient settings. Our manual has been structured for providing CBT during individual outpatient psychotherapy. Another feature that sets our approach apart is the focus on a flexible yet consistent implementation of CBT in children and adolescents with moderate to severe anger/irritability and physical aggression in the outpatient setting. The manual provides guidelines for flexible delivery by allowing therapists to select from several numbered activities that correspond to each session's treatment goals, which can be matched to targeted behavioral problems on the one hand and to the child's motivation and developmental level on the other hand. Lastly, the manual contains treatment fidelity checklists to aid in evaluating treatment adherence, an important part of implementing treatment in a reliable fashion (Perepletchikova and Kazdin 2005 ).

Considerations for Future Research

Although a considerable number of clinical studies have been dedicated to physical aggression, little is known about the treatment of relational aggression. Relational aggression refers to hurting others by damaging their personal relationships or social status, in contrast to overt aggression, which involves hurting someone by physical means (Crick and Grotpeter 1995 ). Although less apparent than overt aggression, relational aggression is associated with depression, social anxiety, and loneliness (Roecker Phelps 2001 ). To our knowledge, all treatment studies that include relational aggression outcome measures have been conducted in school settings (Leff et al. 2010 ). A recent study of a 15-week curriculum focused on communication and problem-solving skills for reducing various types of aggression, which showed a decrease in physical aggression, but no change in relational aggression (Espelage et al. 2013 ). A review of 13 classroom-based prevention programs showed small effect sizes on measures of relational aggression, and concluded that these programs were less effective in addressing relational aggression than overt aggression. A two-pronged approach would help in the development of evidence-based treatments for relational aggression. First, studies of existing behavioral treatments for children with externalizing disorders should include measures of relational aggression. Second, targeted interventions for this form of aggression in children with clinically significant levels of relational aggression should be tested in randomized controlled trials.

Treatment of anger and aggression in the context of co-occurring anxiety and depression poses questions about the sequencing of interventions for primary and secondary symptoms, as well as what risk factors might contribute to the co-occurrence of externalizing and internalizing problems. On the one hand, some studies show that treatment of the primary mood disorder may result in the reduction of associated behavioral problems (Jacobs et al. 2010 ). On the other hand, disruptive behavior may reduce compliance with psychosocial interventions for internalizing symptoms and contribute to functional impairments conferred by the primary diagnoses (Garcia et al. 2010 ). Children with elevated symptoms of anxiety/depression demonstrate greater gains following treatment with parent training (Ollendick et al. 2015 ) and CBT for aggressive behavior (Jarrett et al. 2014 ). It has been suggested that a combination of permissive and controlling/hostile parenting styles may contribute to co-occurring anxiety and conduct problems (Granic 2014 ) and parent-focused treatments have been increasingly used for treatment of anxiety in children (Forehand et al. 2013 ). Similar techniques of cognitive restructuring and problem solving are used within CBT approaches for anxiety/depression and aggressive behavior, which suggests commonality in the emotion regulation skills that are taught to improve both internalizing and externalizing disorders.

Relatively little is known about the treatment of conduct problems in children with callous-unemotional traits (i.e., lack of guilt and empathy). These traits have been associated with persistent and more severe forms of antisocial behavior as well as with distinct neurocognitive deficits in reward processing and social perception (Blair et al. 2015 ). It has been suggested that reduced sensitivity to negative consequences in children with conduct disorder complicated by callous-unemotional traits may reduce the effectiveness of rewards and discipline-focused components of PMT (Hawes et al. 2014 ). At the same time, the increased parental warmth and sensitivity that has been observed following treatment with PMT (O'Connor et al. 2013 ), may serve as the critical element of family-based interventions for ameliorating the lack of empathy and shallow affect conferred by the callous-unemotional traits. One study showed that a 6-hour program that included teaching emotion recognition skills directly to children with high callous-unemotional traits was more effective than parent training, but the effect size for this difference was relatively small (Dadds et al. 2012 ). This suggests that similar and, perhaps, longer treatments that teach emotion recognition and social problem-solving skills directly to children in combination with parent-focused interventions that increase parental warmth and the quality of parent–child interactions may be helpful for children with callous-unemotional traits. These hypotheses are awaiting investigation in randomized controlled trials.

Conclusions

PMT and CBT have been well studied in randomized controlled trials in children with disruptive behavior disorders, and studies involving the transdiagnostic approach to CBT for anger and aggression are currently underway. More work is needed to develop treatments for other types of aggressive behavior (i.e., relational aggression) that have been relatively neglected in clinical research. The role of callous-unemotional traits in response to behavioral interventions and treatment of irritability in children with anxiety and mood disorders also warrants further investigation.

Clinical Significance

Anger/irritability and aggression are among the most frequent reasons for mental health referrals in children and adolescents. PMT is a form of behavioral therapy that aims to ameliorate patterns of family interactions that produce antecedents and consequences that maintain the child's anger and aggression. CBT is another well-studied psychosocial treatment for anger and aggression in children and adolescents. During CBT, children learn how to regulate their frustration, improve their social problem-solving skills, and role-play assertive behaviors that can be used during conflicts instead of aggression. Both PMT and CBT can be offered in the format of time-limited psychotherapy in outpatient mental health centers.

Disclosures

Dr. Denis Sukhodolsky receives royalties from Guilford Press for a treatment manual on cognitive-behavioral therapy for anger and aggression in children. Dr. Stephanie Smith, Ms. Spencer McCauley, Mr. Karim Ibrahim, and Dr. Justyna Piasecka report no conflicts of interest.

• Aman MG, Bukstein OG, Gadow KD, Arnold LE, Molina BSG, 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: 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 :47–60.e41, 2014 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders , 5 th edition. Washington, DC: American Psychiatric Association; 2013 [ Google Scholar ]
• Bandura A: Aggression: A Social Learning Analysis . Oxford: Prentice-Hall, 1973 [ Google Scholar ]
• Barkley RA: Defiant Children: A Clinician's Manual for Assessment and Parent Training , 3rd ed. New York: Guilford Press; 2013 [ Google Scholar ]
• Bearss K, Johnson C, Smith T, Lecavalier L, Swiezy N, Aman M, McAdam DB, Butter E, Stillitano C, Minshawi N, Sukhodolsky DG, Mruzek DW, Turner K, Neal T, Hallett V, Mulick JA, Green B, Handen B, Deng Y, Dziura J, Scahill L: Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: A randomized clinical trial . JAMA 313 :1524–1533, 2015 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Berkowitz L, Harmon–Jones E: Toward an understanding of the determinants of anger . Emotion 4 :107–130, 2004 [ PubMed ] [ Google Scholar ]
• Blair RJ, Leibenluft E, Pine DS: Conduct disorder and callous-unemotional traits in youth . N Engl J Med 372 :784, 2015 [ PubMed ] [ Google Scholar ]
• Blanchard–Fields F, Coats AH: The experience of anger and sadness in everyday problems impacts age differences in emotion regulation . Dev Psychol 44 :1547–1556, 2008 [ PubMed ] [ Google Scholar ]
• Budman CL, Rockmore L, Stokes J, Sossin M: Clinical phenomenology of episodic rage in children with Tourette syndrome . J Psychosom Res 55 :59–65, 2003 [ PubMed ] [ Google Scholar ]
• Burke JD, Boylan K, Rowe R, Duku E, Stepp SD, Hipwell AE, Waldman ID: Identifying the irritability dimension of odd: Application of a modified bifactor model across five large community samples of children . J Abnorm Psychol 123 :841–851, 2014 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Carlson GA: Who are the children with severe mood dysregulation, a.k.a. “rages”? Am J Psychiatry 164 :1140–1142, 2007 [ PubMed ] [ Google Scholar ]
• Connor DF: Aggression and antisocial behavior in children and adolescents . New York: Guilford Press; 2002 [ Google Scholar ]
• Crick NR, Grotpeter JK: Relational aggression, gender, and social-psychological adjustment . Child Dev 66 :710–722, 1995 [ PubMed ] [ Google Scholar ]
• Dadds MR, Cauchi AJ, Wimalaweera S, Hawes DJ, Brennan J: Outcomes, moderators, and mediators of empathic-emotion recognition training for complex conduct problems in childhood . Psychiatry Res 199 :201–207, 2012 [ PubMed ] [ Google Scholar ]
• Deater–Deckard K: Recent research examining the role of peer relationships in the development of psychopathology . J Child Psychol Psychiatry . 42 :565–579, 2001 [ PubMed ] [ Google Scholar ]
• Deffenbacher JL, Lynch RS, Oetting ER, Kemper CC: Anger reduction in early adolescents . J Couns Psychol 43 :149–157, 1996 [ Google Scholar ]
• Dodge KA: Do social information-processing patterns mediate aggressive behavior? In: Causes of conduct disorder and juvenile delinquency . Edited by Lahey B.B., Moffitt T.E., Caspi A. New York: Guilford Press; 2003; pp. 254–274 [ Google Scholar ]
• Dodge KA, Bates JE, Pettit GS. Mechanisms in the cycle of violence . Science 250 :1678–1683, 1990 [ PubMed ] [ Google Scholar ]
• Dretzke J, Davenport C, Frew E, Barlow J, Stewart–Brown S, Bayliss S, Taylor RS, Sandercock J, Hyde C: The clinical effectiveness of different parenting programmes for children with conduct problems: A systematic review of randomised controlled trials . Child Adolesc Psychiatry Mental Health 3 :7, 2009 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Espelage DL, Low S, Polanin JR, Brown EC: The impact of a middle school program to reduce aggression, victimization, and sexual violence . J Adolesc Health 53 :180–186, 2013 [ PubMed ] [ Google Scholar ]
• Eyberg SM, Nelson MM, Boggs SR: Evidence-based psychosocial treatments for children and adolescents with disruptive behavior . J Clin Child Adolesc Psychol 37 :215–237, 2008 [ PubMed ] [ Google Scholar ]
• Feindler EL, Ecton RB: Adolescent Anger Control: Cognitive-behavioral Techniques . New York: Pergamon Press; 1986 [ Google Scholar ]
• Forehand R, Jones DJ, Parent J: Behavioral parenting interventions for child disruptive behaviors and anxiety: What's different and what's the same . Clin Psychol Rev 33 :133–145, 2013 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Frick PJ, Lahey BB, Loeber R, Tannenbaum L, Van Horn Y, Christ MAG, Hart EA, Hanson K: Oppositional defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample . Clin Psychol Rev 13 :319–340, 1993 [ Google Scholar ]
• Garcia AM, Sapyta JJ, Moore PS, Freeman JB, Franklin ME, March JS, Foa EB: Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment study (POTS I) . J Am Acad Child Adolesc Psychiatry 49 :1024–1033, 2010 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Gershoff ET: Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review . Psychol Bull 128 :539–579, 2002 [ PubMed ] [ Google Scholar ]
• Granic I: The role of anxiety in the development, maintenance, and treatment of childhood aggression . Dev Psychopathol 26 :1515–1530, 2014 [ PubMed ] [ Google Scholar ]
• Guerra NG, Slaby RG: Cognitive mediators of aggression in adolescent offenders: Intervention . Dev Psychol 26 :269–277, 1990 [ Google Scholar ]
• Gundersen K, Svartdal F: Aggression replacement training in Norway: Outcome evaluation of 11 Norwegian student projects . Scandinavian J Ed Res 50 :63–81, 2006 [ Google Scholar ]
• Havighurst SS, Wilson KR, Harley AE, Prior MR, Kehoe C: Tuning in to kids: Improving emotion socialization practices in parents of preschool children–findings from a community trial . J Child Psychol Psychiatry 51 :1342–1350, 2010 [ PubMed ] [ Google Scholar ]
• Hawes DJ, Price MJ, Dadds MR: Callous-unemotional traits and the treatment of conduct problems in childhood and adolescence: A comprehensive review . Clin Child Fam Psychol Rev 17 :248–267, 2014 [ PubMed ] [ Google Scholar ]
• Hudley C, Graham S: An attributional intervention to reduce peer-directed aggression among African-American boys . Child Dev 64 :124–138, 1993 [ PubMed ] [ Google Scholar ]
• Jacobs RH, Becker–Weidman EG, Reinecke MA, Jordan N, Silva SG, Rohde P, March JS: Treating depression and oppositional behavior in adolescents . J Clin Child Adolesc Psychol 39 :559–567, 2010 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Jarrett M, Siddiqui S, Lochman J, Qu L. Internalizing problems as a predictor of change in externalizing problems in at-risk youth . J Clin Child Adolesc Psychol 43 :27–35, 2014 [ PubMed ] [ Google Scholar ]
• Kassinove H, Tafrate RC: Anger Management: The Complete Treatment Guidebook for Practitioners . Atascadero, CA: Impact Publishers; 2002 [ Google Scholar ]
• Kazdin AE: Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents . New York: Oxford University Press; 2005 [ Google Scholar ]
• Kazdin AE, Siegel TC, Bass D: Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children . J Consult Clin Psychol 60 :733–747, 1992 [ PubMed ] [ Google Scholar ]
• Kendall PC: Guiding theory for therapy with children and adolescents . In: Child and Adolescent Therapy: Cognitive-Behavioral Procedures . Edited by Kendall P.C. New York: Guilford Press; 2006; pp. 3–30 [ Google Scholar ]
• Kjelsberg E: Pathways to violent and non-violent criminality in an adolescent psychiatric population . Child Psychiatry Hum Dev 33 :29–42, 2002 [ PubMed ] [ Google Scholar ]
• Leff SS, Waasdorp TE, Crick NR: A review of existing relational aggression programs: Strengths, limitations, and future directions . School Psych Rev 39 :508–535, 2010 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Leibenluft E: Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths . Am J Psychiatry 168 :129–142, 2011 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Leibenluft E, Stoddard J: The developmental psychopathology of irritability . Dev Psychopathol 25 :1473–1487, 2013 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Lochman JE, Barry TD, Pardini DA: Anger control training for aggressive youth . In: Evidence-Based Psychotherapies for Children and Adolescents . Edited by Kazdin A.E., Weisz J.R. New York: Guilford Press; 2003; pp. 263–281 [ Google Scholar ]
• Lochman JE, Wells KC, Lenhart LA: Coping Power: Child Group Program . New York: Oxford University Press; 2008 [ Google Scholar ]
• Loeber R, Burke JD, Pardini DA: Development and etiology of disruptive and delinquent behavior . Annu Rev Clin Psychol 5 :291–310, 2009 [ PubMed ] [ Google Scholar ]
• Loeber R, Green SM, Kalb L, Lahey BB, Loeber R: Physical fighting in childhood as a risk factor for later mental health problems . J Am Acad Child Adolesc Psychiatry 39 :421–428, 2000 [ PubMed ] [ Google Scholar ]
• Losel F, Beelmann A: Effects of child skills training in preventing antisocial behavior: A systematic review of randomized evaluations . Ann Am Acad Pol Soc Sci 587 :84–109, 2003 [ Google Scholar ]
• Michelson D, Davenport C, Dretzke J, Barlow J, Day C: Do evidence-based interventions work when tested in the “Real World?” A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior . Clin Child Fam Psychol Rev 16 :18–34, 2013 [ PubMed ] [ Google Scholar ]
• Nagin D, Tremblay RE: Trajectories of boys' physical aggression, opposition, and hyperactivity on the path to physically violent and nonviolent juvenile delinquency . Child Dev 70 :1181–1196, 1999 [ PubMed ] [ Google Scholar ]
• Nock MK, Kazdin AE, Hiripi E, Kessler RC: Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: Results from the National Comorbidity Survey Replication . J Child Psychol Psychiatry 48 :703–713, 2007 [ PubMed ] [ Google Scholar ]
• O'Connor TG, Matias C, Futh A, Tantam G, Scott S: Social learning theory parenting intervention promotes attachment-based caregiving in young children: Randomized clinical trial . J Clin Child Adolesc Psychol 42 :358–370, 2013 [ PubMed ] [ Google Scholar ]
• Ollendick TH, Greene RW, Austin KE, Fraire MG, Halldorsdottir T, Allen KB, Jarrett MA, Lewis KM, Whitmore Smith M, Cunningham NR, Noguchi RJP, Canavera K, Wolff JC: Parent management training and collaborative and proactive solutions: A randomized control trial for oppositional youth . J Clin Child Adolesc Psychol 2015. Epub ahead of print [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Patterson GR, DeBaryshe BD, Ramsey E: A developmental perspective on antisocial behavior . Am Psychol 44 :329–335, 1989 [ PubMed ] [ Google Scholar ]
• Perepletchikova F, Kazdin AE: Treatment integrity and therapeutic change: Issues and research recommendations . Clin Psychol Sci Pract 12 :365–383, 2005 [ Google Scholar ]
• Potegal M, Kosorok MR, Davidson RJ: Temper tantrums in young children: 2. Tantrum duration and temporal organization . J Dev Behav Pediatr 24 :148–154, 2003 [ PubMed ] [ Google Scholar ]
• Ramsden SR, Hubbard JA: Family expressiveness and parental emotion coaching: Their role in children's emotion regulation and aggression . J Abnorm Child Psychol 30 :657–667, 2002 [ PubMed ] [ Google Scholar ]
• Roecker Phelps CE: Children's responses to overt and relational aggression . J Clin Child Adolesc Psychol 30 :240–252, 2001 [ PubMed ] [ Google Scholar ]
• Salmon K, Dittman C, Sanders M, Burson R, Hammington J: Does adding an emotion component enhance the Triple P-Positive parenting program? J Fam Psychol 28 :244–252, 2014 [ PubMed ] [ Google Scholar ]
• Samson AC, Hardan AY, Podell RW, Phillips JM, Gross JJ: Emotion regulation in children and adolescents with autism spectrum disorder . Autism Res 8 :9–18, 2015 [ PubMed ] [ Google Scholar ]
• Scahill L, Sukhodolsky DG, Bearss K, Findley DB, Hamrin V, Carroll DH, Rains AL: A randomized trial of parent management training in children with tic disorders and disruptive behavior . J Child Neurol 21 :650–656, 2006 [ PubMed ] [ Google Scholar ]
• Scott S, Briskman J, O'Connor TG: Early prevention of antisocial personality: Long-term follow-up of two randomized controlled trials comparing indicated and selective approaches . Am J Psychiatry 171 :649–657, 2014 [ PubMed ] [ Google Scholar ]
• Shure MB, Spivack G: Means-ends thinking, adjustment, and social class among elementary-school-aged children . J Consult Clin Psychol 38 :348–353, 1972 [ PubMed ] [ Google Scholar ]
• Silver JM, Yudofsky SC: The Overt Aggression Scale: Overview and guiding principles . J Neuropsychiatry Clin Neurosci 3 :S22–29, 1991 [ PubMed ] [ Google Scholar ]
• Skinner BF: The Behavior of Organisms: An Experimental Analysis . New York: Free Press; 1938 [ Google Scholar ]
• Spielberger CD: Manual for the State-Trait Anger Expression Inventory (STAXI) . Odessa, FL: Psychological Assessment Resources; 1988 [ Google Scholar ]
• Storch EA, Jones AM, Lack CW, Ale CM, Sulkowski ML, Lewin AB, De Nadai AS, Murphy TK: Rage attacks in pediatric obsessive-compulsive disorder: Phenomenology and clinical correlates . J Am Acad Child Adolesc Psychiatry 51 :582–592, 2012 [ PubMed ] [ Google Scholar ]
• Stringaris A, Goodman R: Three dimensions of oppositionality in youth . J Child Psychol Psychiatry 50 :216–223, 2009 [ PubMed ] [ Google Scholar ]
• Sukhodolsky DG, Golub A, Stone EC, Orban L: Dismantling anger control training for children: A randomized pilot study of social problem-solving versus social skills training components . Beh Ther 36 :15–23, 2005 [ Google Scholar ]
• Sukhodolsky DG, Gorman BS, Scahill L, Findley DB, McGuire J: Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: A multiple-baseline design study . J Anxiety Disord 27 :298–305, 2013 [ PubMed ] [ Google Scholar ]
• Sukhodolsky DG, Kassinove H, Gorman BS: Cognitive-behavioral therapy for anger in children and adolescents: A meta-analysis . Aggress Violent Beh 9 :247–269, 2004 [ Google Scholar ]
• Sukhodolsky DG, Ruchkin V: Evidence-based psychosocial treatments in the juvenile justice system . Child Adolesc Psychiatr Clin N Am 15 :501–516, 2006 [ PubMed ] [ Google Scholar ]
• Sukhodolsky DG, Scahill L: Cognitive-Behavioral Therapy for Anger and Aggression in Children , New York: Guilford Press; 2012 [ Google Scholar ]
• Sukhodolsky DG, Scahill L: Disruptive behavior in persons with Tourette Syndrome: Phenomenology, assessment, and treatment . In: Treating Tourette Syndrome and Tic Disorders . Edited by Woods D.W., Piacentini J.C., Walkup J.T. New York: Guilford Press; 2007; pp. 199–221 [ Google Scholar ]
• Sukhodolsky DG, Scahill L, Zhang H, Peterson BS, King RA, Lombroso PJ, Katsovich L, Findley D, Leckman JF: Disruptive behavior in children with Tourette's syndrome: Association with ADHD comorbidity, tic severity, and functional impairment . J Am Acad Child Adolesc Psychiatry 42 :98–105, 2003 [ PubMed ] [ Google Scholar ]
• Sukhodolsky DG, Solomon RM, Perine J: Cognitive-behavioral, anger-control intervention for elementary school children: A treatment outcome study . J Child Adolesc Group Ther 10 :159–170, 2000 [ Google Scholar ]
• Sukhodolsky DG, Vander Wyk B, Eilbott J, McCauley SA, Ibrahim K, Crowley MJ, Pelphrey KA: Neural mechanisms of cognitive-behavioral therapy for aggression in children: Design of a randomized controlled trail within the RDoC construct of frustrative non-reward . J Child Adolesc Psychopharmacol 2016. In press [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sukhodolsky DG, Vitulano LA, Carroll DH, McGuire J, Leckman JF, Scahill L: Randomized trial of anger control training for adolescents with Tourette's Syndrome and disruptive behavior . J Am Acad Child Adolesc Psychiatry 48 :413–421, 2009 [ PubMed ] [ Google Scholar ]
• Vitiello B, Stoff DM: Subtypes of aggression and their relevance to child psychiatry . J Am Acad Child Adolesc Psychiatry 36 :307–315, 1997 [ PubMed ] [ Google Scholar ]
• Wakschlag LS, Tolan PH, Leventhal BL: Research review: 'Ain't misbehavin': Towards a developmentally-specified nosology for preschool disruptive behavior . J Child Psychol Psychiatry 51 :1–22, 2010 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Whelan YM, Stringaris A, Maughan B, Barker ED: Developmental continuity of oppositional defiant disorder subdimensions at ages 8, 10, and 13 years and their distinct psychiatric outcomes at age 16 years . J Am Acad Child Adolesc Psychiatry 52 :961–969, 2013 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Wyatt Kaminski J, Valle LA, Filene JH, Boyle CL: A meta-analytic review of components associated with parent training program effectiveness . J Abnorm Child Psychol 36 :567–589, 2008 [ PubMed ] [ Google Scholar ]