CHILDHOOD ANGER: COGNITIVE BEHAVIORAL PLAY THERAPY

What is Anger?

Anger is one of the basic emotions, a universal emotion that belongs to the common human experience regardless of age, culture, or ethnicity. Like all emotions, anger can have an adaptive function. Anger is rooted in the instinct to defend oneself to survive in the environment and/or to respond to a perceived or experienced injustice. Anger becomes dysfunctional for the child when its expression becomes harmful to themselves or others. Some children struggle to develop the capacity to regulate their emotions and behavior, with consequent impairment and exclusion from age-appropriate activities.

How does Anger present during childhood?

In developmental age, a child may show considerable anger in the following situations:

• Has difficulty calming down when angry.
• Becomes angry easily and is irritable most days.
• Shows a hot-tempered temperament and extreme anger reactions.
• Is verbally or physically aggressive toward self or others in response to frustrations or limits.
• Is uncooperative and does not respect rules.
• Argues with adults most days.
• Breaks rules when supervised by an adult.
• May express anger with biting, kicking, throwing objects at adults or siblings.

When such responses occur, it is important to understand the motivations behind them and to provide children and parents with tools to learn to manage them so that these manifestations become more contained and controlled. If these manifestations are underestimated and not addressed, there is a risk of developing conduct disorder, intermittent explosive disorder, and other related conditions.

When does Anger occur and what are its causes?

Anger can manifest in children for several reasons, including:

• Lack of confidence in their own abilities.
• Difficulties expressing themselves that generate frustration.
• Difficulties in executive functions.
• Need to be heard and cared for.

Risk factors for dysfunctional anger arise from a complex interaction between genes and environment. It has been hypothesized that genes modulating serotonin and monoamine oxidase activity play a role in anger regulation. Temperamental factors related to the child include negative affectivity and low control capacities.

Childhood Anger and Cognitive Behavioral Play Therapy  (CBPT)

The ideal treatment involves the involvement of school, family, and the child, and includes pharmacological intervention where and when necessary.

Cognitive Behavioral Play Therapy (CBPT) has grown over the last 20 years and is increasingly used as a treatment of choice for children. Play is their language, and during a play therapy session children are free and open to learning. CBPT can incorporate cognitive and behavioral techniques in a fun, nonthreatening format. Because interventions are engaging and playful, children adapt and engage in their treatment.

The therapeutic powers of play—facilitating communication, self-regulation, and direct and indirect teaching (Schaefer & Drewes, 2014), can help children identify and communicate their problems through play and participate more fully in treatment. (Antshel et al., 2014; Harris et al., 2005; Kaduson, 1997b; Raggi & Chronis, 2006). A vital aspect of using play therapy is that the child is actively involved, practices skills, and develops competencies needed in treatment (Abdollahian et al., 2013; Kaduson, 1997a).

Evidence shows that cognitive-behavioral treatment can yield positive outcomes. CBPT adds the important element of play to tasks and techniques. The pleasure and positive sensations of play allow children to experience more positive feelings that counteract negative impacts on teachers, parents, siblings, and peers who tell them to stop, pay attention, and behave well (Kaduson, 1997b).

CBPT is a structured, brief, goal-oriented therapy whose objectives are shared with the child and family. The child is welcomed into a play setting designed to create the therapeutic alliance, and parents follow a parallel pathway aimed at learning and strengthening parenting competencies.

The intervention is organized into the following phases:

1. ORIENTATION PHASE: This initial phase emphasizes preparing both the child and the parents. It is crucial to organize an initial meeting between the therapist and the parents, without the child present, to examine the child’s history and background information in detail. This allows parents to share their perception of the child’s problem. During these initial meetings, the therapist assists parents in preparing the child for the first session. The ongoing role of parents and other significant adults in assessment and treatment is explained. Although attention is focused on the child during CBPT, the therapist continues to interact regularly with parents to offer support and evaluate progress toward therapeutic goals.
2. ASSESSMENT PHASE: This phase focuses on collecting crucial information to establish therapy goals. In addition to interviews with parents, a key element is observation of the child’s play. Instruments used may include questionnaires administered to parents, assessment of the child’s play, assessment of family play, the puppet sentence-completion task, and other measures personalized by the therapist. The therapist may establish a baseline for the frequency of the child’s behaviors, allowing evaluation of behavioral changes over the course of treatment.
3. CASE CONCEPTUALIZATION PHASE: CBPT begins with analysis of the data collected during assessment to plan an effective treatment and provide a logical structure for developing and achieving therapeutic goals. The therapist explains childhood anger, analyzing individual, relational, and environmental factors related to parents’ concerns. The child’s emotions, thoughts, physical sensations, and coping strategies are examined. This phase also includes analysis of protective, risk, and maintaining factors that contribute to the child’s behavior.
4. INTERVENTION PHASE: The intervention phase focuses on using CBT techniques that help the child develop more adaptive responses to problems, situations, and stressors that underlie their anger. Emphasis is on learning more adaptive thoughts and behaviors. Methods include modeling, role-playing, bibliotherapy, generalization, and relapse prevention. Interventions often adapt traditional cognitive techniques through play tools such as drawing and expressive arts, therapeutic storytelling, or interaction with puppets facing similar situations. Treatment includes interventions to help the child generalize behaviors learned during sessions to other contexts and to work on relapse prevention. Although the primary focus is on the child, it is important to maintain regular meetings with parents to monitor progress, assess and intervene in parent–child interactions, and provide guidance on areas of concern.
5. CONCLUSION PHASE: Both the child and the family are actively involved in the final phase of therapy. During this period the child addresses feelings related to the end of therapy while the therapist highlights changes and consolidates learning. Final sessions may be spaced out over time, moving from weekly to biweekly or monthly meetings. This helps the child perceive their ability to manage life without the therapist. The therapist positively reinforces the child’s progress between sessions and seeks to normalize the experience of separation. Follow-ups are scheduled at 3 months, 6 months, 12 months, and 24 months to verify intervention effectiveness.

CASO CLINICO 

What are the Therapeutic Goals?

In CBPT, goal-setting is shared with the child and their family. In cases of childhood anger, typical objectives include:

• Teach systematic strategies that guide the child to plan behavior across life domains and solve problems (Problem Solving).
• Develop the capacity to monitor actions and build self-regulation against impulsivity.
• Learn to extract important information from errors for self-correction and to reward oneself for achieving positive results.
• Increase social skills through rule compliance, development of more effective interactions, and the ability to decode others’ emotional states to respond and relate appropriately and functionally.

What can Parents do?

To facilitate intervention with children, parents must be trained on how to understand and manage their children’s behavior and how to be the supporters the child needs.

PARENT TRAINING IN COGNITIVE BEHAVIORAL PLAY THERAPY

Although the primary work is with the child, it is important to meet periodically with parents. Parental involvement in Cognitive Behavioral Play Therapy (CBPT) is essential both during assessment and throughout treatment. A parallel pathway to the child’s therapy is planned, emphasizing the fundamental role of parents in influencing their children’s maladaptive behaviors. Parents are often encouraged to strengthen and reinforce the child’s adaptive behavior so that treatment continues outside the therapy setting (for example, they are trained to use appropriate reinforcement for adaptive behaviors and extinction for maladaptive ones).

Target Population: Intended for both parents.

Duration: Typically 6 to 14 sessions, organized as one weekly session of 1 hour.

The program is structured into the following phases:

1. ASSESSMENT PHASE: The problem is analyzed, parenting style is adapted, and therapeutic goals are defined. In this phase parents receive information about the causes and consequences of their children’s dysfunctional behaviors and learn to establish clear and consistent rules.
2. LEARNING PHASE: This phase focuses on teaching new learnings of all the fundamental skills needed to support the child’s change. Parents have the opportunity to learn and practice techniques through practice sessions in which the therapist role-plays the child, guiding and instructing the parents. Specific targets include:

• Mastery of prerequisites
• Modeling of skills
• Role-playing
• Errorless learning
• Successive approximations (shaping)
• Feedback (verbal and social reinforcers; token economy)
• Practice

3. PRACTICE PHASE: Parents conduct play sessions with their own children to put the learned skills into practice. They learn to recognize and prevent situations that trigger difficult behaviors and to apply the same problem-solving strategies across different contexts. After initial practice moments with the therapist, parents begin to run play sessions individually with their children under the therapist’s supervision.
4. FEEDBACK AND GENERALIZATION PHASE: Parents discuss with the therapist the play sessions carried out at home to learn how to generalize what they have learned. Strengths and any problems that arose are reviewed. The therapist helps parents generalize all learned interventions and the parenting skills acquired during training. Each week some time is dedicated to applying techniques in everyday life, and homework assignments are given to practice the strategies.
5. CONCLUSION PHASE: This phase occurs when therapeutic goals have been met and parents have achieved a satisfactory level of competence regarding play activities and parenting skills. Therapy is often tapered gradually, reducing session frequency to alternate weeks, then monthly, and so on.

Objectives of Parent Training

This program helps parents interact effectively with their child by developing functional behavioral and communicative habits and techniques. The intervention aims to remove conditions that give rise to problem behaviors and to replace them with adaptive and socially desirable conduct. Objectives focus on preventing dysfunctions, promoting well-being, and improving crisis conditions.

Specific objectives of working with parents include:

• Increase their understanding of the child’s problematic behaviour;
• Establish more realistic expectations;
• Increase warmth, trust, and acceptance toward the child.
• Understand the importance of interaction through play.
• Communicate more effectively with their children.
• Develop greater parental confidence and reduce frustrations experienced with their children.
• Develop greater patience to create more realistic expectations.
• Discuss personal reactions with the therapist to gain a deeper understanding of their own feelings and behaviours;
• Learn to become better problem solvers of family conflicts and develop stronger motivation for change.

Bibliography – References

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders — Fifth Edition (DSM-5). Italian translation.
• Abdollahian, E., Mokhber, N., Balaghi, A., & Moharrari, F. (2013). The effectiveness of cognitive-behavioral play therapy on the symptoms of attention-deficit/hyperactivity disorder in children aged 7–9 years. ADHD Attention Deficit and Hyperactivity Disorders, 5(1), 41–46.
• Antshel, K. M., Faraone, S. V., & Gordon, M. (2012). Cognitive Behavioral Treatment Outcomes in Adolescent ADHD. Journal of Attention Disorders, 18(6), 483-495.
• Favaro, A., & Sambataro, F. (2021). Manuale di psichiatria. Piccin.
• Geraci, M. A. (2022). La play therapy cognitivo-comportamentale. Armando Editore.
• Geraci, M. A. (2023). Comprendere il mondo dei bambini giocando. Armando Editore. 
• Geraci, M. A. (2024). Il mondo della dottoressa Lulù. CBPT Books (Amazon series).
• Harris, K. R., Danoff Friedlander, B., Saddler, B., Frizzelle, R., & Graham, S. (2005). Self-Monitoring of Attention Versus Self-Monitoring of Academic Performance: Effects Among Students with ADHD in the General Education Classroom: Effects Among Students with ADHD in the General Education Classroom. The Journal of Special Education, 39(3), 145-157. 
• Kaduson, H. G., Cangelosi, D., & Schaefer, C. E. (Eds.). (1997). The playing cure: Individualized play therapy for specific childhood problems. Jason Aronson.
• Knell, S. M. (1993). Cognitive Behavioral Play Therapy. J. Aronson.
• Pandolfi, E. (2010). I Disturbi Esternalizzanti nell’Infanzia: fattori di rischio e traiettorie di sviluppo. Semestrale, School of Specialization in Cognitive Psychotherapy and Association of Cognitive Psychology, 50.
• Raggi, V.L., Chronis, A.M. Interventions to Address the Academic Impairment of Children and Adolescents with ADHD. Clin Child Fam Psychol Rev 9, 85–111 (2006). 
• Schaefer, C. E., & Drewes, A. A. (Eds.). (2013). The therapeutic powers of play: 20 core agents of change (2nd ed.). John Wiley & Sons.
• Zero to Three. (2018). DC: 0–5. Classification of Mental Health and Developmental Disorders of Infancy. Giovanni Fioriti Editore. Rome.

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