ANGER CONTROL FOR PEOPLE WITH LEARNING DISABILITIES: A CRITICAL REVIEW (original) (raw)
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The British Journal of Psychiatry, 2013
There is a strong body of empirical and theoretical work linking anger and aggression. 1 Anger regulation is a problem for many people with intellectual disabilities and is associated with significant problems of aggression. 2-4 Consequences of aggression include exclusion from services, breakdown of residential placements, involvement with the criminal justice system and adverse effects on the psychological well-being of care staff 5 and family carers 6,7 and potentially the quality of care they provide. Cognitive-behavioural therapy (CBT) is the treatment of choice for common mental health problems, 10 and widening access to CBT is seen as a major policy priority. 11 However, the delivery of CBT to people with intellectual disabilities is underdeveloped and evidence of its effectiveness in this population is lacking. Apart from two small trials in depression, 12,13 anger is the only psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with intellectual disabilities. Large effect sizes have typically been reported. 3,14 However, these studies have a number of methodological shortcomings, including some or all of: non-random allocation to groups; small numbers of participants, therapists and treatment sites; limited range of assessments; absence of a therapy manual; and where a manual was used, no assessment of the fidelity of the intervention.
Background Anger is often expressed as verbal or physical aggression. Prevalence estimates for problem anger among people with intellectual disabilities vary between 11% and 27%. Estimates for significant aggression have a similar range of 6-24%. Aggression is the main reason for an adult with intellectual disability to be seen as having severe challenging behaviour. It may lead to exclusion from services, breakdown of residential placements, involvement with the criminal justice system, adverse effects on the psychological well-being of staff and family carers, and increased costs of health and social care services that individuals receive. Cognitive-behavioural therapy (CBT) is the treatment of choice for common mental health problems and widening access to CBT is a policy priority. However, CBT has been adapted for people with intellectual disabilities only recently and evidence of its effectiveness is not fully developed. Anger is the main psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with intellectual disabilities, but rigorous randomised studies have yet to be undertaken. The current literature includes evaluations of manualised CBT, in which care staff are recruited as 'lay therapists'. There are potential advantages to this approach for ongoing support, dissemination to other staff, service commitment to the approach and efficient use of more scarce professional resources. Objectives The objectives of the study were to: z evaluate the impact of a manualised CBT anger management intervention, delivered by day service staff, on reported anger among people with mild to moderate intellectual disabilities z evaluate its effect on related outcomes, including anger coping skills, aggression, mental health and quality of life z evaluate the extent to which similar results are observed by carers in the home setting as in day services z analyse the extent to which service user or carer characteristics or the conduct of the intervention influence outcome z ascertain the experience of service users, lay therapists and service managers who participate in or host the intervention z evaluate the costs of the intervention and its impact on health and social care resource use z develop methods in the course of the trial: (a) an instrument for monitoring the fidelity of the intervention, and (b) a self-rating version of the Profile of Anger Coping Skills (PACS) to complement third-party rating by carers. Methods A cluster randomised controlled trial was conducted involving 30-day services for adults with intellectual disabilities in Scotland, England and Wales. Ethical approval was granted by the South East Wales Research Ethics Committee (09/WSE03/41). Study population, case definition and study criteria The services that were recruited reported problem anger in at least four service users who were eligible and prepared to participate, had at least two staff willing to be trained as lay therapists, a supportive © Queen's Printer and Controller of HMSO 2013. This work was produced by Willner et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising.
Advances in Mental Health and Learning Disabilities, 2009
Anger has been shown to be associated with aggression and violence in adults with learning disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger in these patient populations. However, it has been suggested that the effectiveness of these interventions is significantly affected by verbal ability. In this service evaluation study the pre-and post-treatment and 12-month follow-up assessment scores of 83 offenders with learning disabilities who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was a function of measured verbal IQ. The results indicate that, overall, the effectiveness of anger treatment was not the result of higher verbal ability as reflected in verbal IQ scores. It is concluded that cognitive behavioural therapy for anger control problems can be effective for people with moderate, mild and borderline levels of intellectual functioning and forensic histories.
Assessment of Anger-Related Cognitions of People with Intellectual Disabilities
Behavioural and cognitive psychotherapy, 2016
Interventions for anger represent the largest body of research on the adaptation of cognitive behavioural therapy (CBT) for people with intellectual disabilities. The extent to which the effectiveness of these interventions reflects the behavioural or cognitive components of CBT is uncertain. This arises in part because there are few measures of anger-related cognitions. The Profile of Anger-related Cognitions (PAC) is built around interpersonal scenarios that the participant identifies as personally anger-provoking, and was designed as an extension of the Profile of Anger Coping Skills (PACS). A conversational presentational style is used to approach ratings of anger experienced in those situations and of four relevant cognitive dimensions: attribution of hostile intent, unfairness, victimhood, and helplessness. The PAC, and other measures, including the PACS, was administered to (i) people with ID identified as having problems with anger control (n = 12) and (ii) university studen...
British Journal of Clinical Psychology, 2005
Objectives: Anger is a significant predictor and activator of violent behaviour in patients living in institutional settings. There is some limited evidence for the value of cognitivebehavioural treatments for anger problems with people with intellectual disabilities. In this study a newly designed treatment targeted at anger disposition, reactivity and control was provided to intellectually disabled offenders with aggression histories living in secure settings. Design: Forty detained patients with mild-borderline intellectual disabilities and histories of serious aggression were allocated to specially modified cognitive-behavioural anger treatment (AT group) or to routine care waiting-list control (RC group) conditions. Methods: AT group participants received 18 sessions of individual treatment. The AT and RC groups were assessed simultaneously at 4 time points: screen, pre-and posttreatment, and at 4-months follow-up using a range of self-and staff-rated anger measures. The effectiveness of the treatment was evaluated using ANCOVA linear trend analyses of group differences on the main outcome measures. Results: The AT group"s self-reported anger scores on a number of measures were significantly lower following treatment, compared to the RC wait-list condition, and these improvements were maintained at follow-up. Limited evidence for the effectiveness of treatment was provided by staffs" ratings of patient behaviour post-treatment. Conclusions: Detained men with mild-moderate intellectual disabilities and histories of severe aggression can successfully engage in and benefit from intensive an individual cognitive-behavioural anger treatment that also appears to have beneficial systemic effects.
Cognitive-Behavioural Treatment of Anger Intensity among Offenders with Intellectual Disabilities
Journal of Applied Research in Intellectual Disabilities, 2002
Background Aggressive behaviour has been identified as a significant problem amongst people with intellectual disabilities living in institutional settings. Anger is a key activator of aggressive behaviour, as well as being an important element of clinical distress related to adverse life experiences. There is some evidence for the value of cognitive-behavioural treatments for anger problems with people having intellectual disabilities. No controlled studies of anger treatment involving intellectually disabled offenders living in secure settings have been conducted to date. A pilot study of an elaborated anger treatment protocol for this client population was undertaken, comparing the specialised anger treatment with routine care. Methods Detained men with intellectual disabilities and histories of offending were allocated to specially modified cognitive-behavioural anger treatment (n ¼ 9) or to routine care waiting-list control (n ¼ 10) conditions. Eighteen sessions of individual treatment were delivered over a period of 12 weeks. Treatment outcome was evaluated by participants' self-report of anger intensity to an inventory of provocations and by staff-ratings of the anger attributes of participants' ward behaviour. Results Participants' reported anger intensity was significantly lower following the anger treatment, compared to the routine care wait-list condition. There were largely no treatment condition effects in staff-rated anger. Limited evidence for the effectiveness of anger treatment was provided by the staff ratings of participant behaviour post-treatment. Conclusions Detained offenders with intellectual disabilities can benefit from intensive individual cognitive-behavioural anger treatment. Further research is required to examine the mechanisms for change and their sustainability.
Journal of Intellectual & Developmental Disability, 2017
Background: Poor anger regulation is considered a risk factor of aggression in individuals with mild or borderline intellectual disabilities. Psychomotor therapy (PMT) targets anger regulation through body-and movement-oriented interventions. This study aims to inform practitioners on efficacy and research-base of PMT in this population. Method: This systematic review evaluated nine studies which met inclusion criteria in terms of participants, intervention procedures, outcomes and certainty of evidence. Results: Seven studies revealed a substantial reduction of aggressive behaviour or anger. Certainty of evidence was rated inconclusive in most cases due to absence of experimental control. Conclusions: We can conclude that body-oriented PMT, involving progressive relaxation and meditation procedure "Soles of the Feet", is a promising approach. However, the paucity of studies and methodological limitations preclude classifying it as an evidence-based practice. This suggests stronger methodological research and research aimed at PMT's mechanisms of action (e.g., improved interoceptive awareness) is warranted.
Knowledge about anger in children with a mild intellectual disability
International journal of special education, 2022
The knowledge of children with a mild intellectual disability (ID) is less complex and poorer than that of their peers in the intellectual norm (IN). The aim of this study was to characterize knowledge about anger in children with mild intellectual disabilities. The study used the authoring tool to measure children's knowledge of emotions, including anger. This tool facilitated the exploration of the cognitive representation of the basic emotions available in three codes (which perform the functions of perception, expression, and understanding) and the interconnections between them. Children in the intellectual norm (N = 30) and children with mild intellectual disabilities (N = 30) participated in the study. The results mainly indicated differences in how anger was understood by particular groups, to the detriment of children with a disability. The results were largely determined by the child's level of organization of knowledge about anger and accompanying mental operations.