Regulation Over Restraints – Specialized Behavior Therapy for Juveniles with Aggression Difficulties

Featured Article | International Journal of Forensic Mental Health  | 2023, Vol. 22, No. 3, 175-186

A Study on the Effects of Responsive Outpatient Aggression Regulation Therapy for Juveniles

L. M. Hoogsteder; De Waag, Forensic Outpatient Treatment Center de Waag, Forensic Care Specialists, Utrecht, The Netherlands; Program Group: Forensic Child and Youth Care, University of Amsterdam, Amsterdam, The Netherlands

P. Oomen; De Waag, Forensic Outpatient Treatment Center de Waag, Forensic Care Specialists, Utrecht, The Netherlands

N. Sweers; De Waag, Forensic Outpatient Treatment Center de Waag, Forensic Care Specialists, Utrecht, The Netherlands

J. Hendriks; Program Group: Forensic Child and Youth Care, University of Amsterdam, The Netherlands

Effectiveness of Responsive Outpatient Aggression Regulation Therapy (ReARTOutpatient) for juveniles with severe aggression problems was investigated. Methods: Re-ARTOutpatient for juveniles (n=44) was compared with a control group (n=48) receiving treatment as usual on several treatment outcome measures. Results: Re-ART-Outpatient showed significantly better results on risk of violent recidivism, impulsivity, motivation, handling anger, self-reported aggressive behavior, and cognitive distortions. Discussion: This could be explained because Re-ART is systemic and individualistic, targeting various aggression-related criminogenic risk factors. Further research with adequate sample sizes, randomized, at multiple locations, with data on actual recidivism, is recommended.

Aggression; control group; impulsivity; risk of violent recidivism; juveniles

“Severe violent crimes are committed by juveniles relatively often…Non-treatment or intervening too late increases the chance of recidivism and/or persistent aggressive behavior later in life…This study investigates the efficacy of the intervention Responsive Aggression Regulation Therapy (Re-ART) Outpatient for juveniles…Re-ART-Outpatient for juveniles was developed for juveniles between 12 and 16 years old with feelings of anger that lead to (severe) aggression problems…This target group often shows behavioral disorders, regularly combined with stress and trauma-related complaints…ADHD and/or substance abuse…In this study, the effects of Re-ART for juveniles are investigated by comparing the risk of violent recidivism, impulsivity, handling anger, motivation, family functioning, aggressive behavior, coping, and cognitive distortions in the Re-ART group, to those in a control group…” (p. 175-177).

“This study was conducted at seven locations of an outpatient forensic psychiatric treatment center in the Netherlands…Some juveniles come with a referral from their general practitioner, others are referred by the police or the judiciary, due to issues such as domestic violence, aggression outside the family or other criminal behavior…The results showed that the Re-ART-Outpatient for juveniles was more effective than TAU [treatment as usual] (no difference between CBT and PLL) in reducing the risk of violent recidivism…We found that where juveniles reported a decrease in aggressive behavior, their parents reported no significant change. Only a medium effect was found in the Re-ART group and a small effect in the TAU group on this factor. This suggests that Re-ART is not superior to TAU interventions in addressing aggressive behavior reported by parents and measured with the CBCL…As expected, Re-ART-Outpatient for juveniles did not improve family functioning above that found for TAU…In contrast to the results of Re-ART-Outpatient for young adults…no significant difference was found in active and palliative coping. Both groups demonstrated a small improvement in positive change in palliative coping, but active coping did not improve across both groups…” (p. 177-182).

“The outcome regarding cognitive distortions leading to unassertive behavior was striking. Juveniles in the Re-ART group scored higher on this variable, but only with a small effect size. Re-ART puts significant effort in improving cognitive distortions, for instance by using the modules Influence of thinking and Self Image…This process could strengthen cognitions leading to unassertive behavior as it can evoke thoughts and feelings of shame and guilt…Among juveniles in the control group, cognitions leading to distrust increased. Feelings of insecurity may increase due to a lack of individual attention and/or insufficient transparency about the parental part of the treatment whereby the juvenile is not present…” (p. 182).

“…Re-ART uses several effective elements. Re-ART mainly consists of individualized treatment (group treatment for this forensic population is considered less effective…) and of elements from cognitive behavioral therapy…It is important to create a workable therapeutic relationship…by validating juveniles (showing empathy, making an effort to understand the client, helping to understand what the person is feeling and thinking…). Validating the client helps to reduce feelings of anger and distrust and lets them process their emotions. For example, therapists can use ‘helping thoughts,’ positive thinking (McCart & Sheidown, 2016; Oostermeijer et al., 2017) and imagination exercises. To process emotions and reduce cognitive distortions, improve mentalization and teach juveniles several useful skills, drama therapeutic techniques such as role playing…and ‘chair techniques’ (Van der Wijngaart, 2022) are utilized. To achieve stress reduction, the treatment also contains relaxation and adapted mindfulness exercises” (p. 176).

“…Given the specific age group investigated in this study, it is possible that the coping capacities of the juveniles were not yet fully developed, leading to difficulties in choosing the most effective coping style and/or using more active and palliative coping styles…In that case, the current methodology of Re-ART for juveniles does not seem to be sufficiently effective in this area. Juveniles could possibly benefit further from Re-ART-Outpatient when given more assistance in developing effective coping styles (either active or palliative). By exercising these effective coping styles, improvement in coping could be possible” (p. 182).

“As expected, the ANCOVA showed no moderating effects of ethnicity (migration background vs. no migration background), nor for MID (yes/no) on the various outcome variables, except for impulsivity. Juveniles with MID benefitted less from Re-ART in reducing impulsivity compared to juveniles without MID. A possible explanation could be that individuals with intellectual disabilities are, in general, more impulsive (Luteijn et al., 2017). The group of juveniles with MID in our sample could, therefore, reman more impulsive and for that reason, the treatment could be less effective for this group” (p. 182).

“To explain aggressive behavior in relation to cognitive and emotional processes, Re-ART uses the cognitive behavioral therapeutic model (CBT mode; Beck &Haigh, 2014). This model is based on the social and cognitive learning theory and assumes that aggressive behavior is a consequence of the individual applying dysfunctional schemata. These schemata play a central role in social information processing and determine emotional reactions and behavior. Dysfunctional schemata are described as powerful beliefs and expectations which are formed based on experiences in childhood and adolescence…As well as the impact of dysfunctional schemata, executive dysfunction (working memory, cognitive flexibility and inhibition) has also been connected to the development and continuation of aggressive behavior…” (p. 176).

As always, please join the discussion below if you have thoughts or comments to add!

• AAFP: Assessment of Risk for Violence in Juveniles
• Behavioral Principles in Dialectical Behavior Therapy (DBT - 5)