Keywords

7.1 Emotion Competence and Regulation in Young Children

Emotional competence is a noteworthy concept in children’s development. Children must gain mastery over understanding the meaning of emotions before expressing and regulating emotions. In 2000, Saarni proposed a model of emotional competence which emphasized cognitive and social moderators including awareness of one’s own emotions, the skills to discern the emotions of others, and the capacity to cope adaptively with difficult emotions (Saarni, 2000; Suveg et al., 2007). One aspect of emotional competence is emotional knowledge or understanding. Pons and Harris (2000) developed the Test of Emotion Comprehension (TEC) to assess the hypothesized domains of emotional understanding. These domains have improved our understanding about how to guide youth through learning and understand the function and impact of their emotions. These domains are recognition of emotions, based on facial expressions; the comprehension of external emotional causes; impact of desire on emotions; emotions based on beliefs; memory influence on emotions; possibility of emotional regulation; possibility of hiding an emotional state; having mixed emotions; contribution of morality to emotional experiences.

While youth must learn to understand their emotions, they must also master inhibitory control, the ability to inhibit or suppress salient thought processes or behaviors that are not relevant to the goal or task at hand (Carlson & Wang, 2007). Mostly develop this control mechanism during the preschool years, but if children do not develop these skills, they are left with poor inhibitory control and become easily frustrated and prone to reactive aggression.

Finally, the concept of emotion regulation (ER) has been emphasized in both the developmental and clinical literature. ER refers to the regulation of the experience of an emotion first by monitoring one’s expressive behavior (Carlson & Wang, 2007). Then as an internal modulation of triggered emotions via the application of various behavioral and cognitive strategies (Cole & Jacobs, 2018). Explicit awareness of emotion regulation strategies emerges between ages 3 and 5 years. Then, over the preschool period, children acquire a new range of skills such as theory of mind, the capacity to inhibit a dominant response and the process of cognitive reappraisal (Sala et al., 2014). This crucial emotion regulation strategy requires that the child changes their ways of thinking about an emotional trigger in order to regulate their response. Overall, a review of available research indicates a universal acceptance of the idea that understanding one’s emotional life is a central component of children’s socio-emotional competence and adjustment.

7.2 Anger and Aggression in Young Children

Some aggression is normative in early childhood and generally declines during the transition to elementary school. Coinciding with language acquisition and increased expressive vocabularies, children between the ages of 2 and 5 years tend to rely less on physical forms of aggression and more on verbal abilities for emotional expression (Wilson & Ray, 2018). However, children who are persistently aggressive are at greater risk for poor academic and interpersonal outcomes (Evans et al., 2019). Aggressive behavior problems in young children are one of the most frequent referral issues for clinicians and since early patterns may predict later antisocial behaviors, early interventions are fundamental (Robson et al., 2020). Many risk factors that lead to the development of anger and aggression problems have been identified. These include a difficult or uninhibited temperament, deficiencies in affect regulation and social information processing, hostility biases and misappraisals, and poor problem-solving skills. Contextual risk factors have focused on parents who provide harsh discipline, poor monitoring, and inconsistent contingency management (Feindler, 1995). Finally, coercive patterns of family interactions and the absence of positive parenting behaviors are also influential in the development and maintenance of aggressive behavior patterns.

Emotion regulation, the ability to manage anger and frustration, influences the development of cognitive and social skills necessary for prosocial functioning. Young children who exhibit aggressive behaviors most likely experience intense levels of negative affect and have few internal coping skills to manage their emotions. Children struggling with their self-regulatory processes often lack the ability to control their feelings and emotions and therefore may display aggressive behaviors out of impulse. High impulsiveness most commonly characterizes conflicts related to self-regulation and aggression. Very young children often express aggression through impulsive acts related to their feelings of anger, frustration, and the like (Wilson & Ray, 2018). Further, empathy and self-regulation are identified components of aggression that theoretically contributes to a child’s inhibition and expression of aggressive acts. A child’s ability to experience and demonstrate empathy is directly related to his or her ability to take on the emotional experiences of another and thus is largely connected to regulation of aggressive behavior (Wilson & Ray, 2018).

Within a cognitive behavioral theoretical model, anger is viewed as a subjective experience which can vary in intensity and duration and which emerges across various interpersonal contexts. Anger expression, which includes the ability to show it outwardly, to suppress it deliberately or to cope with it actively, varies between individuals (Sukhodolsky et al., 2004). Anger as one of the many emotions that children learn to master is a complex emotional construct composed of physiological, cognitive, and behavioral components. For young children, the link to aggressive behavior is fairly common and most children learn to control their aggression and express their emotional experience in a socially competent fashion. However, there are significant numbers of children who fail to achieve skills of emotional regulation and impulse control who will then need clinical intervention as early patterns of aggressive behavior tend to remain stable across time. Therefore, early intervention is advised for youth who display aggressive tendencies, have little impulse control, or have difficulty understanding emotions.

During the past 10 years, there has been a proliferation of cognitive behavioral anger management intervention programs. Based on the understanding that children’s aggressive behaviors are the outcome of poor emotion regulation and self-control, programs have been developed to remediate these deficits. Social information processing theory indicates that children’s emotions and subsequent actions (in this case anger and aggression) are regulated by the way they perceive, process, and /or mediate environmental/interpersonal events. Their experiences of frustration and anger are related to identifiable deficits and distortions in this cognitive processing sequence as well as deficits in problem-solving and appropriate anger expression skills. Thus, each child will need to learn ways to manage their subjective emotional experience, to reframe his or her cognitive appraisals of events and to respond to provocation in an effective prosocial manner (Feindler & Gerber, 2008). Yet, teaching young children coping skills and emotion regulation strategies is no easy feat. Play activities offer clinicians an accessible way to connect and work with younger children to improve their emotion regulation.

7.3 The Role of Play

Children’s pretend play has long been proposed as a mode of social interaction that enhances the development of emotion regulation (Hoffmann & Russ, 2012). Pretend play provides children with a unique environment in which to practice and master social and emotional skills. According to Fein (1989) pretend play, by transcending literal meaning, provides a context to process, manifest, and modify experiences involving high levels of emotional arousal. Themes and stories acted out in play help to teach display rules about emotions, such as when and how to express anger as well as model aspects of modulating emotions (Hoffmann & Russ, 2012). Clearly, play is a learning mode for young children and should be incorporated into clinical interventions. Abstract forms of play allow for the processing of emotion reactions, attuning of motivational states, and enhanced understanding of interpersonal interactions (Peterson & Flanders, 2005). Many aggressive young children have difficulty playing imaginatively and instead release their aggressive impulses by acting out during play: hitting, throwing, breaking, biting, etc. Further, they seem to have difficulties engaging in rich or complex play and in coordinating symbolic play themes (Landy & Menna, 2001).

Opinions vary as to the availability of aggressive toys in clinical settings when working with young aggressive children. Some therapists see the use of toys such as the punching bag or Bobo doll, as necessary to a child’s behavioral expression of emotion and underlying conflict (Trotter et al., 2003), while others see aggressive toys as possibly harmful. Schaefer and Mattei (2005) in their review of catharsis and children’s aggression concluded that “when adults permit and encourage children’s release of aggression in play, the children are likely to maintain this behavior at its original level or actually increase it” (p. 107). Therefore, many therapists incorporate the use of structured play to teach children numerous affect expression and regulation skills as well as teach children how to control aggressive impulses. Drewes (2008) concluded that the use of the Bobo doll and other aggressive toys is not effective and recommended alternative expressive material as providing a more constructive and perhaps symbolic means to express emotions. Unfortunately, little recent research comparing these cathartic strategies with other play therapy strategies when working with young aggressive children has been reported.

Instead, we recommend that child therapists work with age-appropriate toys, games, and books while implementing intervention strategies. Knell (2009, and this volume) has described an elegant but practical way to blend play therapy and cognitive behavior therapy for effective work with young children. Table 7.1 includes a list of anger management themed books and YouTube programs for young children to help with a bibliotherapy component as well. In Appendix B, there are several supplemental anger management intervention ideas that can be blended into clinical work with young children along with the Turtle Magic Intervention described next.

Table 7.1 Child-friendly resources
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7.4 Turtle Magic

7.4.1 Turtle Magic Intervention Program Description

Turtle Magic Intervention (TMI) is a short-term therapeutic treatment program originally developed for preschool-aged children informed by tenets of cognitive behavioral play therapy (CBPT). CBPT is based on the cognitive theory of emotional disorders and is designed to be developmentally appropriate for children for a range of presenting problems (Knell, 2009). TMI was originally designed as a pilot treatment for preschool-aged children who demonstrated marked externalizing problems and aggressive behavior in their classroom (Schira, 2018). TMI may be used as a psychoeducational emotion regulation program with young children.

The TMI program aims to teach children the skills necessary to identify and express their emotions, regulate their emotional responses by implementing coping skills, and solve problems in a developmentally appropriate way. TMI may be utilized in an individual or group format. TMI is designed as a nine-session treatment program with sessions lasting approximately 30 min. After the eight core sessions, a ninth “booster” session is administered approximately 1 month later.

7.4.2 About Turtle Magic

The Turtle Magic Intervention was developed to be used in conjunction with the short therapeutic storybook, Turtle Magic, that highlights the core anger management components (Feindler, 2009). The protagonist in the story, Timmy Turtle, struggles to adjust to school and get along with his peers, and can be seen engaging in aggressive and impulsive behaviors. In the story, Timmy Turtle receives a recommendation from the Wise Old Turtle to use his shell as a calm space to relax and consider other possible solutions to a conflict (Feindler, 2009). The phrase “doing a turtle” involves “(a) recognizing anger as it swells, (b) interrupting the swell and pulling inside, (c) taking a few deep breaths and thinking about how to solve the conflict, and (d) returning to the scene and implementing a possible solution” (Feindler, 2009, p. 409). These skills can be applied on the individual level or with group related problems that provoke frustration in young children. Through Turtle Magic, children enhance their narrative abilities and therefore, view multiple perspectives on a situation and further develop their empathy (Feindler, 2009).

7.4.3 TMI Treatment Description

All meetings begin with the welcome song and discussion of the session agenda. The welcome song, described later in the TMI manual, outlines the rules for whole body listening with behavioral descriptions for their eyes, ears, voices, and bodies. Songs and choreographed body movements are playful and engaging ways to orient children to the sessions. Each week the child learns and practices target coping skills. The fundamental coping skills of TMI include relaxation, positive self-talk, and problem-solving. The TMI lessons are designed to progressively build on one another with ample opportunities for review and practice. Throughout each session, the therapist and child refer to the Turtle Magic (Feindler, 1991) storybook to identify and emphasize the skills being learned; the child will also role-play the story content using accompanying animal puppets and other play materials. Children engage in structured activities and games along with peers and the therapist to increase skill generalization. At the end of each session, the child receives a small prize and is awarded a skill badge based on the session’s target skill (e.g., Emotion Badge, Relaxation Badge).

Each of the nine TMI treatment sessions is divided into four components:

1. Welcome/Check-In

The therapist welcomes participants and sings the Welcome Song. The therapist facilitates an emotion check-in e.g., “How are you feeling today?” Next, the therapist reviews the session agenda with the child/group, including a preview of the skill to be learned together

2. Fun & Learning

Each week the child/group will learn a new skill and engage in activities and games aimed at practicing the learned skills

3. Turtle Magic story

After the skill is explained and modeled, the child/group will read the Turtle Magic storybook about a young turtle named, Timmy Turtle, who struggles to adjust to school and get along with his peers, and often engages in aggressive and impulsive behaviors. The children will be instructed to identify the learned skill in the storybook and role-play the skill using animal puppets and play props

4. Reinforcement

At the end of each session, the children receive a small prize and are awarded a badge based on the session content and skill learned (e.g., Emotion Badge, Relaxation Badge)

The following list outlines the materials needed for all the TMI sessions:

• Turtle Magic storybook: (Feindler, 1991) available online from author.

• Puppets (2 minimum): Turtles, one big, one small (Folkmanis Turtle Hand Puppet)

• To Do/Done Checklist: DIY (suggested white board, pen/paper)

• Whole Body Listening Cue Cards https://lessonpix.com/materials/1090565/Picture+Cards

• Stickers, prizes, and badges

• Emotion visual cue cards: happy, sad, angry, excited, surprised, scared

• Handheld Mirror

• Props and toys: Pizza, Stop Sign, Microphone, Thought Bubble

• Freeze Dance Song: https://www.youtube.com/watch?v=2UcZWXvgMZE

• Timmy Turtle problem-solving pages

• Additional animal puppets

• Yoga mat (optional)

The Turtle Magic Intervention- Individual and Group Manual (Fig. 7.1), available below, is available for application with young children in both individual and group formats. The suggested group size is between three and five group participants. Therapists are encouraged to have materials prepared before the session and to structure each session using the four-component outline: Welcome/Check-in, Fun & Learning, Turtle Magic Story, and Reinforcement.

Fig. 7.1
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Turtle Magic Intervention—Individual & Group Manual

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7.4.4 Brief Review of Evidence for Turtle Magic Intervention

Schira (2018) conducted a single-subject, pilot study of TMI to examine the effectiveness and feasibility of the treatment program with three children at a special education preschool who were identified as exhibiting aggressive behaviors. Participants enrolled in the pilot study were 3 years old at the start of treatment. Eligibility was determined based on a T-score of 65 or above on the aggressive problems subscale, a T-score of 65 or above on the oppositional defiant problems subscale, or a T-score of 60 or above on the externalizing problems subscale on the Caregiver-Teacher Report Form for Ages 1 ½ to 5 (C-TRF; Achenbach & Rescorla, 2001). Evaluation of TMI treatment fidelity was coded using video-recorded treatment sessions implemented by a trained mental health professional. Within-participant analyses focused on comparing the subscale T-scores obtained from the C-TRF at three time points: pre (baseline), post (after completion of study), and at 4-month follow-up. Data collected from the C-TRF suggested that Child 1 displayed no significant change from pre- to post-assessment; however, at follow-up assessment, the teacher reported a significant decrease in all three subscales. Child 2 and 3, on the other hand, demonstrated an increase in problematic behaviors from pre- to post-assessment, although these behaviors improved at follow-up assessment (Schira, 2018). Overall, researchers found that there was an improvement in teacher-reported prosocial behaviors from baseline to follow-up and that the treatment was implemented with high fidelity.

An adaptation to TMI was Turtle Magic Intervention for Groups (TMI-G) of young children was developed by Pazmino Koste (2021). Interventions in small groups of children offer increased opportunities for in vivo role-plays of frustration eliciting situations as well as the practice of emotion regulation and social skills with peers. The first study of TMI-G was to examine the treatment acceptability of TMI-G for children with aggressive behaviors and emotion dysregulation. Further, this study examined whether the type of professional degree, years of experience as a school practitioner, or the type of school setting participants are employed would impact acceptability of TMI-G. Knowing the predictors associated with treatment acceptability will help identify who would likely benefit from access to and training in TMI-G, which could foster engagement with the program. Finally, school practitioners were asked their opinion if TMI would be better implemented in an individual, group format, or other, and if preschool-aged children would benefit from the intervention.

Participants for this study included 92 licensed/certified school psychologists, licensed clinical and master social workers, school counselors, and guidance counselors who worked with children between the ages of 3 and 12 years old at preschools and elementary schools in the United States. Participants were recruited to read a case vignette of three aggressive preschoolers, followed by the TMI-G treatment description and then complete self-report questionnaires to assess for treatment acceptability of the Turtle Magic Intervention-Group. Scores on the Treatment Evaluation Inventory-Short Form (TEI-SF, Newton & Sturmey, 2004) range from 9 to 45, with higher scores indicating greater acceptance of a given treatment. A total TEI-SF score of 27 indicates moderate acceptability of a treatment intervention. Results from the present study indicate that participants found TMI-G to be above moderate acceptability (Mean = 33.77, SD = 3.90) for children with aggressive behaviors and emotion dysregulation. Correlations were used to determine the relations between treatment acceptability and type of professional degree, years of experience as a school practitioner, type of school setting, racial and/or ethnic background most prevalent amongst students, and geographical region in the US. No significant correlations were found. School practitioners were also asked if they believed TMI would be better implemented in an individual format, group format, or other. Of the participants, 65.1% indicated TMI would be better implemented in a group format, while 10.8% preferred TMI for individual therapy. Additionally, 24.1% of participants selected “other” and provided short answer responses including TMI as a combination of individual and group therapy, and TMI as a classroom intervention. Of the school practitioners who completed this study, 94% believed preschool-aged children would benefit from TMI, while 6% did not believe it would be appropriate.

Since the TMI approach is so new, there has been limited research on its efficacy for young children. The single-subject pilot study (Schira, 2018) with three aggressive preschoolers indicated teacher observed changes in the right direction at follow-up. Excellent treatment implementation fidelity was also determined for each session of the TMI manual. Since the treatment acceptability study completed by Pazmino Koste (2021) indicated strong acceptability ratings from school mental health practitioners, the logical next step would be to examine treatment outcomes with small groups of children. The small group format was highly endorsed by these school practitioners and we would also recommend adding parent pre-post assessments to future program evaluations.

7.5 Summary

Incorporating play materials, games, stickers/badges, and stories, the Turtle Magic Intervention described in this chapter is based upon the integration of cognitive behavioral concepts and play therapy approaches as a promising treatment of young children with anger and aggression problems. The nine sessions of Turtle Magic Intervention, implemented either individually or in a small group, are engaging and enjoyable for young children and can be easily implemented in school or community settings. Tables 7.1 and 7.2 include child-friendly resources and additional anger management strategies that can be included to extend treatment and/or to supplement the TMI protocol. Although outcome results on TMI are currently limited, the treatment program seems highly acceptable to mental health professionals working with young and aggressive children.

Table 7.2 Supplemental anger management play strategies for kids
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