Anger Management for Adolescents: Efficacy of Brief Group Therapy

Anger Management for Adolescents: Efficacy ofBrief Group Therapy KAREN V. SNYDER, PH.D., PAUL KYMISSIS, M.D., A N D KARL KESSLER, M.D.

ABSTRACT Objectives:To investigate the efficacy of a brief, manual-based group therapy for adolescents with poor anger control. A previously developed anger management treatment package of 10 to 12 sessions was condensed to a 4-session package to be given within 2 weeks. Immediate effectiveness and the transfer of skills were investigated; anger management skills

not only had to be acquired, they also had to be used in the adolescents’ natural social interactions. Method: Fifty adolescent psychiatric inpatients were selected for high levels of anger and randomly assigned to treatment or control conditions. Preand posttreatment measures were administered to subjects and adults who rated the subjects’ behaviors. Results: Pre/post self-report measures, as well as behavior ratings by adults, indicated that the patients who went through the anger management series exhibited significantly improved skills. Conclusions:These results suggested that the interventionfor adolescents was effective even though it was condensed, but it should not be further abbreviated. J. Am. Acad. Child Adolesc. Psychiatry, 1999, 38( 11):1409-1416. Key Words: anger management, adolescent, brief therapy, psychiatric inpatient.

Anger and aggression in child and adolescent populations have been a major concern in society and in clinical settings. The ongoing scientific study of these linked constructs is warranted. The purpose of the study was to investigate the efficacy of an intervention aimed at reducing anger and aggression in an adolescent psychiatric inpatient population. Specifically, it tested their levels of anger, anger control, and aggressive behaviors in experimental and control conditions. Their acquisition of anger management skills, as well as the transfer of these skills to social environments, was measured before and after exposure to the conditions. At the posttreatment phase, behavior ratings were completed by adults in 3 different social environments, thus offering a wider, more representative sample of the adolescents’ social behaviors and self-control during socially provocative in-

teractions with their peers. These included (1) behavior ratings by nursing staff on the hospital unit, (2) behavior ratings by teachers in the special education classroom, and (3) behavior ratings by parentdguardians in the home/ community environment in a 4- to 6-week follow-up phase (i.e., after patients had been discharged from the hospital). Previous studies had demonstrated the efficacy of anger control interventions through longer treatment series (i.e., 10-20 sessions over several months) (e.g., Feindler et al., 1984, 1986). However, the realities of shorter lengths of stay in psychiatric hospitals created the need for the development of shorter, more intensive therapeutic approaches. Thus, it became necessary to develop a 4-session anger management series that could be completed within a 2week time period, roughly corresponding to the average length of stay. Brief Literature Review

AcceptedJune 29, 1999. Dr. Snyder is Clinical Instructor of Psychiatry at New York Medical College and a psychologist f i r the Crisis Intervention Services, Westchester Medical Center, Valhalla, N E Dr. Kymissis is Professor of Clinical Psychiatry and Pediatrics and Dr. Kessler is Assistant Projssor of Psychiatry at New York Medical College. The authors thank New York Medical College and the staff of the Westchester Medical Center adolescentpsychiatric unitfor their participation in the research, and Melonie Seelig, R.N., f i r her insights andfeedback. Reprint requests to Dr. Snyder, Crisis Intervention Services, CPEI;‘Westchester Medical Center, Valhalla, N Y 10595; e-mail.. [email protected]. 0890-8567/99/3811-14090 1999 by the American Academy of Child and Adolescent Psychiatry.

Cognitive-behavioral anger management treatment studies with adolescents emerged from Meichenbaum’s (1977) early work on self-talk strategies with adults and from Novaco’s (1975, 1976) anger management treatment for adult males. Their techniques were modified so that they could be used with children (Camp et al., 1977) and later with adolescents (Feindler et al., 1984, 1986; Goldstein and Glick, 1987).These studies, as well as the literature on anger, aggression, and disruptive behavior disorders (e.g., Bandura, 1973; Berkowitz, 1993; Dodge,

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1991; Dollard et al., 1939; Feshback, 1964; Kazdin, 1987; Patterson, 1974), provided the initial guidelines for teaching anger control skills to adolescents in group formats and steered much of the contemporary literature. The critical reviews concluded that, within the relative paucity of research in this area and on adolescents in general (Kassinove and Sukhodolsky, 1995), it seems that adolescents can acquire anger management skills but that there is a great need for establishing evidence of skill generalizability beyond the therapeutic sessions and into real life situations in which the social interactions are actually occurring (Averill, 1983; Feindler, 1987, 1989, 1991; Goldstein and Pentz, 1984; Kassinove and Eckhardt, 1995; Kazdin et al., 1987; Lochman and Lenhart, 1993). The current study sought to heed these cautions by specifically targeting the issues of skills generalization (transfer) and maintenance in a population of angry and aggressive adolescents. From a cognitive-behavioral theoretical perspective, the study aimed to assess not only the acquisition of anger management skills, but also the active use (i.e., generalization and maintenance) of such skills in natural social interactions. The cognitive view was indicated by the interpretation and verbal labeling of internal arousal levels, angry feeling states, self-statements, attending to social cues, and other cognitive strategies for regulating affect and subsequent behaviors. Cognitions (i.e., appraisals and interpretations of social situations, understandings of emotions, and expectations) and cognitive strategies (e.g., self-statements, strategies for slowing down the response time to allow for more thinking about the problem and possible solutions) were the key elements for change. Behavioral contingencies and the social context (e.g., the therapeutic milieu, acknowledgment of the power of adolescent social interactions, social reinforcers of new skills and behaviors) (Kymissis, 1997) supported these new slulls and enhanced their transfer to natural, social situations. Research Hypotheses

Hypothesesfor Treatment Eficay. Subjects who received the anger management treatment series were hypothesized to self-report significantly less anger at the posttreatment phase, compared with their own pretreatment scores and compared with the posttreatment self-reports of control subjects. These hypotheses permitted tests of the efficacy of the condensed anger management treatment through the self-report measures at posttreatment. Hypotheses for Generalization of Treatment Eficaq. It was further hypothesized that subjects who received the 1410

anger management treatment series would not only benefit from the treatment according to their self-report measures, but also they would generalize their skills into broader social settings. Thus, they would show fewer disruptive behaviors at posttreatment compared with their control subject counterparts. This prediction was tested by behavior rating scales that were completed by 2 different sets of raters, teachers and nursing staff in their respective settings (classroom and hospital unit). These adults observed and rated the experimental and control subjects’ behaviors at the posttreatment phase. These behavior ratings were compared for differences between experimental and control subjects. Hypotbesiszfor Maintenance of Treament Eficaq. Finally, the subjects who received the anger management treatment series were hypothesized to maintain their skills better in a 4- to 6-week follow-up phase (i.e., having fewer disruptive behaviors) when the parentdguardians rated them in the home/community environment, compared with the control subjects. METHOD Subjects Fifty adolescent patients, 28 males and 22 females, in a New York county psychiatric hospital participated in this study. The study was approved by the hospital’s institutional review board. Once the adolescents were admitted to the hospital unit, the selection criteria for inclusion in the study consisted of (1) the treatment team’s recommendation (i.e., due to many indicators of angry thoughdfeelings, disruptive behaviors, and dyscontrol of anger), based on a review of the patient‘s recent history, observations of behavior on the unit, and a semistructured clinical interview; and (2) a score of 75% or higher on the Trait Anger scale of the State-Trait Anger Expression Inventory (STAXI) (Spielberger, 1988). Adolescents who met 60th selection criteria were randomly assigned to either a treatment group or a control group. Demographic information including age, gender, diagnostic category, and categorical changes in psychotropic medication regimen was recorded for each patient who participated in the study (Table 1). In 21 cases, there were changes in the medication regimen during participation in the study. For 17 of these patients, the increases or decreases of dosage amounts were for “p.r.n.” medications. For 3 patients, however, the entire standing medication regimen was altered. All 3 were males, and 2 of them were control subjects whose self-reported anger increased on the Minnesota Multiphasic Personality InventoryAdolescent (MMPI-A) Anger Content scale (pre/post comparisons). The experimental subject’sself-reported anger scores decreased slightly. The precise effect of the psychotropic medications on participants’ abilities to manage their anger was not known, but it is unlikely that medication effects systematically altered these participants’ behaviors because the pre/post-intervention scores adhere closely to the general pattern of the treatment and control groups, respectively. To control for all potential effects, participants were assigned randomly to groups. A broad range of ethnicities was represented in the sample, with a predominance of minorities due to the nature of the patient community served by the hospital. Although these demographics may

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TABLE 1 Demographic Data for Experimental and Control Groups: Frequencies of Gender, Ethnicity, Diagnostic Category, and Changes in Psychotropic Medications (N= 50) Frequency Experimental Group

Control Group

28 22

16

9

12 13

1 25 11 8

0 13

1 12

5

2

31

17

7 5 5

4

Total Gender Male Female Ethnicity Asian African-American White Hispanic Mixed Diagnostic category” Disruptive behavior disorders Adjustment disorders Depressive disorders Psychotic disorders Personality disorders Changes in psychotropic medicationsb Medications increasedladded Medications decreased/ discontinued Standing medication regimen altered Medications withheld 1 day a

6 4

TABLE 2 Anger Management Group Training: Abbreviated Manual for Cotherapists

5 4 3 14 3 4 3

2

1 2 1

13

6

7

4

1

3

3

2 0

1 1

1

number generator using the Apple Computer SANE Mathematics routine (Standard Alpha-Numeric Expressions, Apple Computer, 1986) accessed through Hypercardm (Version 2.35) (Apple Computer, 1987). They then completed the MMPI-A Anger Content scale (Butcher et al., 1992) as a pretreatment measure. The unit chief chose 2 cotherapists from a pool of trained clinicians and direct care staff, and the group series (treatment or control) ran for the next consecutive 2 weeks with 4 to 6 patients in each group. The treatment was the Anger Management Group Training series (Table 2), and the control condition was a series of psychoeducational videotapes on topics relevant to adolescents (Table 3). Each of the group sessions was 45 to 50 minutes long.

1

DSM-IV (American Psychiatric Association, 1994).

Changes in medications were scored according to (1) additions or increases in daily dosages, (2) decreases or discontinuations, (3) major alterations of the standing regimen, or (4) medications withheld for I-day blood testing. offer opportunities to explore additional analyses (e.g., gender differences), they were not used as formally as part of this study’s hypotheses and final analyses. These potential questions are so complex and intriguing that it seems they deserve their own full investigation. The most frequent primary psychiatric diagnoses of subjects who entered the study were disruptive behavior disorders (31 cases). Other comorbid diagnoses were included if the subjects met the criteria and were judged qualified for the study by their psychiatrists. Demographic variables, including psychotropic medication regimens, were found to be comparable across experimental and control groups. Adolescents who met both selection criteria, the treatment team’s recommendation and a high score on the STAXI Trait Anger scale (Spielberger,1988),were randomly assigned to either a treatment group or a control group. All of the usual ethical considerations were given to the subjects of this study (e.g., informed consent from subjects and parendguardians, anonymity, and confidentiality).Attrition accounted for 9 cases, and these cases were not found to differ significantly from the remaining cases on selection criteria variables.

Procedures Subjects who met both selection criteria were assigned randomly to treatment or control conditions. Randomization was done by a random

Session 1: Introduction to Concepts Orientation to the group. Provide structure: Reducing anxiety and resistance. Discuss general concepts of anger: -What does anger feel like in body? Where is it felt? -Anger as interpretations/perceptions of situations. -Styles of handling anger are learned from role models (parents, siblings, older peers, etc.). Participation from group on each of these points, examples. Stay with major ideas; don’t delve too deeply into underlying dynamics. Session 2: Anger Management Concepts: More In-Depth Reiterate: Anger as interpretationslperceptions of situations. Discussion of social misperceptions, misinterpretations, hostile stances. --Interpretations of other people’s behaviors-are they accurate? -Alternative explanations for others’ behaviors (person was just rude, jealous, having a bad day, etc.). -Hostile stances protect us, but are they realistic? -Sometimes anger is appropriate, but how to express it? Concrete strategies for checking one’s own perceptions, controlling angry reactions, choosing more appropriate behaviors. Group members begin to develop individualized strategies for dealing with anger (taking it out on basketball court, walking away, talking it over, using humor, etc.). Session 3: Practice The Anger Control Game (Berg, 1995)-a game designed for this population. Provides concrete opportunities for practice, structured role-plays, naturalistic in vivo provocations, feedback from peers and cotherapists. Session 4:Review and Integration Review of strategies. Hassle Logs (Feindler et al., 1986)--concrete format to bring in personal examples. Role-plays, practice, reviews of the adolescents’ actual social situations. Peer feedback to each other (with coleader guidance) on how effective each person’s responses were, how well they controlled anger. Discussion, opinions about the group, what each person liked about the group.

.

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TABLE 3

Attrition

The Control Condition

A total of 59 patients met both selection criteria, had consent forms signed, and thus were eligible to participate in the study. Of this group, 9 patients were not included in the final sample due to attrition, including 2 patients who were transferred to other hospitals, 1 patient who had a change in guardianship and lack of consent from the second parent, 1 patient who withdrew from the study, 3 patients who missed one of the group therapy sessions, and 2 patients who were discharged from the hospital midway through the group series. The remaining 50 patients constituted the sample for this study.

Session 1: Discussion Starters: Conflict Resolution, Peer Mediation, Teen Activists, and Job Interviewing Skills (WNYC Foundation, 1997b). Session 2:

The Drug Knot (Shapiro and O’Neill, 1986).

Session 3:

The Nutty Pro$ssor (Grazer and Simmons, 1996): Excerpts from a videotape that demonstrates some strategies for responding to provocations/frustrations.

Session 4: Careers: Focus on Your Future (WNYC Foundation, 1997a): An instructional videotape about job interviewing skills and various careers.

RESULTS Pre- and Posttreatment Self-Report Measures

At the posttreatment phase, the MMPI-A Anger Content scale was readministered to all subjects for a prelposttreatment comparison. In addition, teachers recorded their classroom observations of each participant on the Antisocial Behavior scale of the School Social Behavior Scales (SSBS) (Merrell, 1993),and nursing staff recorded their hospital unit-based observations of each subject on the Antisocial Behavior scale of the Home and Community Social Behavior Scales (HCSBS), a parallel form to the SSBS for use outside of classroom settings (Merrell and Caldarella, 1997). Nursing staff and teachers were blind to group assignment. This was easily accomplished with the teachers, whose primary work location was separate from the hospital unit (i.e., in a classroom down the hall). The nursing staff‘s blindness was accomplished by asking only those staff who were not involved in the study (e.g., as cotherapists) to complete the behavior ratings. This meant relying primarily on the evening and weekend staff, as the daytime nursing staff were typically more involved in the daytime group therapies, or at least had many opportunities to notice which patients went into which groups. Moreover, the evening and weekend staff were not aware (or interested) in the research design; they assumed that the psychoeducational video group was just another group. All nursing and clinical staff had a basic level of knowledge and skill for cueing all of the adolescents to use good anger control strategies. Such cueing and guidance was applied across all patients on the unit regardless of their involvement in the study, or their assignment to treatment or control conditions. In fact, it was to the disadvantage of the study that the control subjects were likely to have learned some good anger management skills by virtue of being on the unit. This process was not blocked for obvious ethical reasons. At the follow-up phase, 4 to 6 weeks after treatment, the adolescents were already discharged from the hospital and had returned to their home/community environments. The parendguardians recorded their observations of the subjects on the HCSBS Antisocial Behavior scale and returned them in prepared mailers. Blindness to group assignment was not always possible with the parents, as their discussions with the social workers and psychiatrists frequently ventured into the adolescent’sanger control issues. For a power of 80% and a probability level of .05 (Cohen, 1988; Shavelson, 1988) ir was determined that each of the 2 cells (i.e., experimental and control conditions) needed 25 subjects. This was based on a review of the size of effects for similar treatment studies on aggressive children and adolescents (e.g., Camp, 1977; Feindler et al., 1984;Jurkovic and Prentice, 1977; Knoff and Batsche, 1995). The data were analyzed by using analyses of variance (ANOVAs) (Kirk, 1968).

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The subjects’ scores on the self-report Anger Content scale before and after treatment were analyzed using a 2 X 2 split-plot factorial ANOVA design. Data for this analysis were the raw scores on the MMPI-A Anger Content scale (Butcher et al., 1992), which represented the total number of items endorsed as “true” on that scale. Scores varied from 0 to 17.The ANOVA used the independent variables of treatment levels (experimental versus control) and time (pre- versus postintervention). The dependent variables were the subjects’ scores on the self-report measure. The main effect of treatment level (Fl,48= 2 . 2 , = ~ .14) was nonsignificant. The main effect of time (FI,h8= 1.3, p = .25) was also nonsignificant. However, the treatment X time interaction of this split-plot ANOVA was significant (Fl,48 = 14.3, p < . O l ) , indicating a treatment effect for some groups under particular treatment conditions (Table 4 and Fig. 1 ) . The experimental group’s scores decreased significantly from pre- to posttreatment measurements, whereas the control group‘s scores increased slightly from pre- to posttreatment. This interaction indicated that the subjective experiences of anger and anger control improved for the experimental subjects after treatment. Behavior Ratings

The ratings from teachers and from nursing staff were analyzed using a one-way completely randomized ANOVA design. Treatment subjects were rated as significantly less disruptive than the control subjects at the postintervention phase. Put differently, both teachers and nursing staff perceived the experimental subjects at postintervention as substantially less disruptive than their control counterparts. The main effect of group (treatment versus control subjects) was significant (Fl,48= 4.43, p < .OS). Furthermore, both the teachers and the nursing staff rated the groups with similar patterns; the main effect

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TABLE 4 Means, Standard Deviations, Standard Error, and ANOVA for Repeated Measure of Self-Reported Anger on the MMPI-A Anger Content Scale: Experimental and Control Group Subjects at Pre- and Postintervention Phases ( N =50) Group" Experimental group Pretreatment Posttreatment Control group Pretreatment Posttreatment

Mean'

SD

Range

SE

9.92 8.04

2.25 4.45

5-14 2-14

0.45 0.69

9.92 10.64

3.45 3.01

3-16 5-16

0.69 0.60

4 10.6

10.75 10.00

9.9 9.50 9.00

8.50 8.00

SDlit-Plot ANOVA Source Group Subject (group error term) Category for within Category for within X group Category for within X subject (error term)

df

SS

MS

F

1

42.25 768.56 8.41

42.25 16.01 8.41

2.64

48 1 1

42.25

42.25

48

161.60

3.37

2.85 14.30**

Note: ANOVA = analysis of variance; MMPI-A = Minnesota Multiphase Personality Inventory-Adolescent; SS = sums of squares; MS = mean square. n = 25 each group. Higher mean scores indicate more anger (i.e., more items endorsed). " " p < .01.

8.25 Pie intervention

Fig. 1 Self-report interaction: means for the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) Anger Content scale: experimental and control group. Subjects at pre- and postintervention phases (N= 50).

TABLE 5 Teacher and Nursing Staff Behavior Ratings: Means, Standard Deviations, Standard Error of Measurement, and ANOVA at Posttreatment for Experimental and Control Group Subjects (SSBS and HCBS Antisocial Behavior Scales) ( N =50)

'

of settings (teachers versus nursing staff) was not significant =2.53,~ = .12). The groups X settings interaction also was not significant (F1,48= 0 . 2 4 , ~= .63) (Table 5, Fig. 2). Follow-up Behavior Ratings

The behavior ratings at the 4- to 6-week follow-up phase were not analyzed by the planned t test because there were not enough forms returned by the parentdguardians to make this comparison between experimental and control subjects meaningful (HCSBS Antisocial Behavior scale) (Merrell and Caldarella, 1997).The response rate for parentdguardians who returned their forms was 20% (10/50 cases); the analysis would have had little meaning. DISCUSSION

Two broad questions were addressed by this study. First, the study asked, Can adolescents acquire the skills for anger management when the intervention is condensed into a 4-session series? Second, the study addressed the more complex question, Do these skills generalize to social situations in a meaningful way, and are they maintained?

Postintervention

Group Nursing staff ratings alone Experimental group Control group Teacher ratings Experimental group Control group Combined ratings Experimental group Control group

Mean"

SD

SE

90.40 112.48

23.91 37.05

4.78 7.41

87.12 100.44

25.95 31.35

5.19 6.27

89.18 106.46

24.07 34.50

3.41 4.88

One-way Factorial ANOVA Source Group Subject (group error term) Teacher X nursing staff (Teach. X Nurs.) X group (Teach. X Nurs.) X Subj. (error)

df

SS

MS

F

2,106.81 475.12 216.09

4.43*

1

2,106.81 22,809.48 216.09

1

20.25

20.25

48

4,109.16

85.61

1

48

2.53 0.24

Note: ANOVA = analysis of variance; SSBS = School Social Behavior Scales; HCSBS = Home and Community Social Behavior Scales; SS = sums of squares; MS = mean square; Teach. = behavior ratings done by teachers; Nurs. = behavior ratings done by nursing staff members; Subj. = subjects. " Higher scores indicate greater frequency of disruptive, angry behaviors. * p < .05.

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severe financial strains were less likely to fill out and return a behavior rating scale for a research study.

120 100

Clinical Implications

80

60 40

20 0 Experimental

Control

Fig. 2 Combined teacher and nursing staff behavior ratings of experimental and control group subjects after treatment (Antisocial Behavior scales of the School Social Behavior Scales and the H o m e and Community Social Behavior Scales) (A’=50). M = mean.

Limitations

The first inherent design limitation was that only 1 of the 4 measures, the MMPI-A Anger Content scale (Butcher et al., 1992), was given both before and after the intervention. The emphasis of the design was on multiple measures of anger and angry behaviors (i.e., selfreports as well as 3 ratings of behavior by adults), rather than repeated measures across time (Campbell and Fiske, 1959). O n the basis of observations of this particular facility over 2 years, it was determined that the most valuable, accurate data would come from the nursing staff and teachers who observe the adolescents’ behaviors on a daily basis, but only if the demands on their time could be focused into a one-time posttreatment measurement for each adolescent so that unnecessary strains were not imposed on the treatment milieu in the process of measuring it. The second limitation involves selection criteria. The treatment team’s decision might have been specific to the experience and clinical views of this particular team. Therefore, it may be difficult to replicate this selection criterion in future studies. The inclusion of a quantitative selection criterion, theTrait scale of the STAXI (Spielberger, 1988), partially counteracted this limitation. The third limitation was that follow-up data depended on the cooperation of parentdguardians. Some of the adolescents came from apparently dysfunctional families, indicating that these parentdguardians may have been at risk for a variety of other problems that detracted from their cooperation with a research study. For example, families who experienced ongoing emotional turbulence and

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The significant interaction of the self-report pre/posttreatment measure indicated that the experimental group‘s scores decreased after treatment whereas the control groups scores increased slightly. Thus, the distance between their scores at postintervention increased. This indicated support for the efficacy of the condensed Anger Management Group Training series from the subjective experience (self-report) perspective. It was not clear why the control groups scores increased slightly at postintervention, but this phenomenon was observed previously (Feindler et al., 1986). It may have been due to random variance in the scores or due to the subjects’ general frustrations of being on a locked hospital unit. Future research could clarify this issue by using the technique of postexperimental interview (Orne, 1969). In any case, the results from the self-report measures indicated that the experimental subjects acquired skills and benefited from the Anger Management Group Training series. They reported significantly less anger after treatment than did the control subjects. This suggests that the intervention can be successful in as few as, but not fewer than, 4 sessions. This recommendation was not tested directly, but it is based on the observation of a smaller effect size with 4 sessions compared with 10 to 12 sessions, as well as clinical judgment and common sense that not enough material would be covered in 2 or 3 sessions. It is likely that the previously developed treatment series of 10 or 12 sessions produced more robust effects because of the increased opportunities for structured practice and individualization of strategies, or simply because more is better. If the luxury of time exists in a given therapeutic setting, the conservative choice would be to use a longer group series. However, in the current, rather stringent atmosphere that imposes increasingly brief treatments, this type of focused, brief anger management intervention is likely to be effective with clinical adolescent populations. The second question of generalization and maintenance of skills for anger management was partially addressed by the behavior ratings completed by nursing staff and teachers. The significant difference between groups in the behavior ratings at posttreatment indicated that the experimental subjects not only gained the anger control skills but also generalized these skills beyond the treatment sessions to the immediate hospital and class-

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room settings. In essence, the nursing staff and teachers perceived a positive treatment effect at the end of the 2week treatment program. This finding supported the transfer of anger management skills from the carefully governed environment of the group therapy session to the more varied and more socially demanding environments outside the therapy sessions where newly acquired skills were supported by trained adults. These results must be qualified, however, as the follow-up ratings at 4 to 6 weeks after the treatment were insufficient to analyze the ongoing maintenance of anger management skills. Recommendations for Future Research

The findings of the investigation support the need for the generalization of skills to natural social settings. Aspects of the treatment that enhanced generalization of anger control skills were crucial, and these active ingredients should continue to be emphasized in future studies, as the social utility of such brief treatments continues to be an area of concern that is well worth ongoing investigation. Specifically, future studies should find ways to elicit more information about the generalization and maintenance of skills in the weeks and months that follow the end of the treatment program. The incorporation of anger management training into the outpatient therapy program would also be helpful so that there is support for the transfer of skills into daily social interactions. Efforts to extrapolate laboratory research into real-world problems continue to be a clear challenge for future research. The importance of social validity emerges not only from the anger management literature, but also from a broader perspective of treatment studies (e.g., Hoagwood et al., 1995).While the efficacy of treatments can be investigated with more scientific rigor in laboratory settings, the actual effectiveness of such treatments ultimately must be studied in social environments and situations that approximate real life. For behaviorally disrupted adolescents, psychiatric hospital units and contained special education classroom settings provide good matches for “stretching the research design to encompass effectiveness issues” (Clark, 1995, p. 718). O n one hand, it is recommended that future investigations use increasingly naturalistic settings to assess the adolescents’ application of anger management skills. O n the other hand, the literature in this area is so sparse that there are many different perspectives that would contribute meaningfully to extend the current knowledge of the field.

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Novaco R (1975), Anger Control: The Development and Evaluation of an Experimental Treatment. Lexington, MA: Heath Novaco R (1976), The treatment of anger through cognitive and relaxation controls. Consulr Clin Psychol44:68 1-685 Orne M T (196% Demand characteristics and the concept of quasi-controls. In: Artifct in Behavioral Research, Rosenthal R, Rosnow R, eds. New York: Academic Press, pp 147-179 Patterson G (l974), Interventions for boys with conduct problems: multiple settings, treatments, and criteria. J Consult Clin Pychol42:471-481 Shapiro A, O’Neill J, producers (1986), The DrugKnot(vide0tape) (available from Walt Disney Educarional Media Company, CBS Entertainment Productions) Shavelson RJ (1988), Statistical Reaxoningfor the Behavioral Sciences, 2nd ed. Boston: Allyn & Bacon Spielberger C D (1988), State- Trait Anger Expression Inventory: ProferJional Manual. Odessa, FL: Psychological Assessment Resources WNYC Foundation, creators (1997a), Careers: Focus on Your Future (videotape, edited to 45 minutes) (available from Castle Works, Inc., PO Box 56, Briarcliff, NY 10510) WNYC Foundation, creators (1997b), Discussion Starters: Conjict Resolution, Peer Mediation, Teen Activists, and Job Interviewing Skills (videotape, edited to 45 minutes) (available from Castle Works, Inc., PO Box 56, Briarcliff, NY 10510)

Sexual Orientation and Risk of Suicide Attempts Among a Representative Sample ofyouth. Robert Garofalo, M D , R. Cameron Wolf, MS, Lawrence S. Wissow, M D , M P H , Elizabeth R. Woods, M D , MPH, Elizabeth Goodman, M D

06jective:To examine whether sexual orientation is an independent risk factor for reported suicide attempts. Design: Data were from the Massachusetts 1995 Centers for Disease Control and Prevention Youth Risk Behavior Survey,which included a question on sexual orientation. Ten drug use, 5 sexual behavior, and 5 violencelvictimization variables chosen a priori were assessed as possible mediating variables, Hierarchical logistic regression models determined independent predictors of suicide attempts. Setting; Public high schools in Massachusetts. Participants: Representative, population-based sample of high school students. Three thousand three hundred sixty-five (81%) of 4167 responded to both the suicide attempt and sexual orientation questions. Main Outcome Measure: Self-reported suicide attempt in the past year. Results: One hundred twenty-nine students (3.8%) self-identified as gay, lesbian, bisexual, or not sure of their sexual orientation (GLBN). Gender, age, racelethnicity, sexual orientation, and all 20 health-risk behaviors were associated with suicide attempt (P< ,001). Gay, lesbian, bisexual, or not sure youth were 3.4 1 times more likely to report a suicide attempt. Based on hierarchical logistic regression, female gender (odds ratio [OR], 4.43; 95% confidence interval [CI], 3.30-5.93), GLBN Orientation (OR, 2.28; 95% CI, 1.39-3.37). Hispanic ethnicity (OR, 2.21; 95% CI, 1.44-3.99), higher levels of violencelvictimization (OR, 2.06; 95% CI, 1.80-2.36), and more drug use (OR, 1.31; 95% CI, 1.22-1.41) were independent predictors of suicide attempt (P<,001). Gender-specific analyses for predicting suicide attempts revealed that among males the O R for GLBN orientation increased (OR, 3.74; 95% CI, 1.92-7.28), while among females GLBN orientation was not a significant predictor of suicide. Conclusions: Gay, lesbian, bisexual, or not sure youth report a significantly increased frequency of suicide attempts. Sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization behaviors. Arch Pediav Adolesc Med 1999;153:487-493. Copyright 1999, American Medical Association.

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