797p03 - using anger assessment in children and adolesncents

Using Anger Using Anger Assessment in Children Assessment in Children

and Adolescents to and Adolescents to Develop Treatment PlansDevelop Treatment Plans

Raymond DiGiuseppe, Ph.D., D.Sc., ABPPSt. John's University

andThe Albert Ellis Institute

Anger AssessmentAnger Assessment

1) Total scale scores may be in the normal range yet the person may experience a clinical problem with some aspects of anger. Total anger scores may not be as informative.

2) Since people think anger is not a problem, they may not store all of the information together. Open-ended questions may not be as helpful as is usually the case as in other disorders.

Test Type of Test

The Aggression Questionnaire (AQ) Buss &

Perry (1992)

Self-report measure of aggression, including physical aggression,

Anger Inventory (NI) Novaco (1977)

An 80-item 5-point Likert Scale that was developed as an index of anger reactions to provoking incidents.

Anger Self-Report (ASR) Zelin, Adler & Myerson (1972)

A 64-item Likert type scale constructed to differentiate between the awareness and expression of aggression.

Attitude Towards Guns and Violence (AGVQ) Shapiro

(1997)

A 26-item instrument that measures violence-related attitudes.

Becomes Angry Scale (BAS)Siegel (1984)

A 19-item rating scale that assesses the frequency of anger expression as well as the range of situations that

will evoke anger.

Buss-Durkee Hostility Inventory (BDHI) Buss &

Durkee (1957)

A self-report multidimensional test that was developed to assess various aspects of hostility.

Child Self-Control Rating Scale (CSCRS) Rohrbeck,

Azar & Wagner (1991)

A 33-item 4-point scale. It uses an alternative question format. It is intended to supplement traditional

teacher/parent perspectives on children's self-control.

Conners-Wells' Adolescent Self-Report Scale: Long Form (CASS:L) Conners &

Wells (1997)

An 87 item Likert response scale. Measure of psychopathology, specifically targeting ADHD. Anger

Control Problems is one of ten subscales. It is appropriate for youths 12-17.

MMPI-A Hathaway, McKinley & the Adolescent Project

Committee (1992)

A 478-item true/false objective measure of psychopathology. Anger and Cynicism are two of the

fifteen content scales. It is intended for adolescents ages 14-18.

Multidimensional Anger Inventory (MAI) Siegel

(1986)

A self-report test of the multidimensional nature of anger.

Multidimensional School Anger Inventory (MSAI)

Smith, Furlong, Bates & Laughlin (1998)

A 31-item Likert response scale developed to measure affective, cognitive, and behavioral components of

anger.

Novaco Anger Inventory (NAS) Novaco (1994)

A self-report measure designed to assess the environmental provocations, cognitions, emotional

arousal, and behaviors elicited by anger.

The Pediatric Anger Expression Scale (PAES)

Jacobs, Phelps & Rohrs (1989)

A 15-item self-report measure designed to assess anger as a multidimensional construct.

Reaction Inventory (RI)Evans & Stangeland (1971)

A 76 item questionnaire developed to measure anger expressed by an individual under specific situations. Subjects respond on a 5 pt. scale from "not at all" to

"very much."

S-R Inventory of Hostility Jaderlund & Waldron (1968)

A 5 pt. Likert type scale containing 14 situations considered to be frustrating and to evoke anger.

State-Trait Anger Expression Inventory-2

Spielberger (1994)

Provides measures of the experience, expression, and control of anger, measured by 2 components: State and

trait anger for adolescents and adults.

The Teacher's Self-Control Rating Scale (TSCRS)

Humphreys (1982)

A 15-item 5-point Likert teacher rating scale designed to assess school behavior problems and self-control.

Anger Disorder ScaleAnger Disorder Scale

Multi-dimensional nature: 5 Domains and 18 Subscales.

Each factor or sub-scale has implications for treatment and represents an aspect of anger observed in clients.

The number of sub-scales reflects our beliefs concerning what a clinician should know to plan effective treatment.


Behavior Domain< Verbal aggression < Physical aggression< Passive aggression< Indirect aggression< Relational aggression< Anger in

Arousal Domain< Duration of Axis I Problem < Episode Length< Physiological reactivity


Cognitive Domain< Rumination < Impulsivity< Suspiciousness< Resentment

Provocations< Hurt / Social Rejection < Scope of anger


Motives Domain• Coercion• Revenge• Tension Reduction

Higher Order Factor Score• Verbal Expression• Anger In• Vengeance


This scale clearly distinguishes Angry clients and forensic samples from: – Normal controls– General Psychotherapy Outpatients– Child & Adolescent Version presently being

normed.

Published by MultiHealth Systems

Toronto, Ontario Canada

Anger Disorder Scale –Anger Disorder Scale –Youth VersionYouth Version

Factor structure is very similar Impulsivity and rumination do not separate into

different factors but merge as one. Physical, verbal, indirect, and relational aggression load

together as one factor. No sex differences for Relational Aggression. Tension reduction is a weak factor in adults but much

stronger in adolescent, This was confirmed in H. Luttinger’s dissertation with a different method.

Cluster AnalysisCluster AnalysisWard's Method Squared Euclidian DistancesAn Inverse Scree test of the Agglomeration

values created the Clustering Analysis.13 clusters were identified as the best fit.We analyzed 12,14 & 15 cluster solutions.We then used Discriminate Function Analysis to

confirm the results (Percent of accurate classification).

Cluster AnalysisCluster Analysis

This uses the subscales to predict cluster membership. Also, Kappa coefficients were used to see which solution produced the most reliable categories.

More clusters produced different levels of the same patterns.

Fewer clusters missed some important groups.

960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982

cluster

1500000

2000000

2500000

3000000

Me

an

D

X-13 Cluster Form Here

Inverse Scree of Aggolmoration Values

Table 2

Anger In ClustersAnger In Clusters

• Several clusters characterized by Anger In.• They had some elevations on Passive

Aggression.• Anger-In is characterized by Suspiciousness

and resentment.• Triggered by social rejection.

40

45

50

55

60

65

70

75

80

Me

an

The Resentful, Vengeful, High Intesity, Anger-In Profile

Figure 15.6

Non Confrontational AngerNon Confrontational Anger

Not all aggression is impulsive, or confrontational.

This cluster is vengeful, ruminative and non impulsive.

The dominance of the Instrumental / Affective-Impulsive aggression distinction has blinded us to planned anger motivated aggression.

40

45

50

55

60

65

70

75

80

Me

an

NonConfrontational Vengeance Profile

Cluster 9 of 13

Verbal not Relational AggressionVerbal not Relational Aggression

Here is a subtype with high coercion, revenge and verbal arguing.

This is a profile most likely reserved for the family.

50

55

60

65

70

75

80

85

90

Me

an

Verbal, Not Relational Aggressive Profile

Cluster 12 of 13

Pure IED?Pure IED?

We get a group that is impulsively aggressive with AVERAGE TRAIT ANGER.

Furlong and Smith find a group like this is boys.

40

45

50

55

60

65

70

75

80

T S

co

res

The Poly-Aggression with Moderate Anger Profile

Figure 15.2

High Anger and High AggressionHigh Anger and High Aggression

Many people have both disturbed anger and aggression.

60

65

70

75

80

85

90

95

100

105

110

Me

an

Extreme Anger and Aggression Cluster

Cluster 13 of 13

What Diagnosis?What Diagnosis?

Several DSM include anger but it is neither necessary nor sufficient to reach the diagnosis.– Oppositional Defiant Disorder– Conduct Disorder– Borderline PD


Other Aggressive or Impulsive Diagnoses include– IED– Bipolar

Anger and Impulse or Manic Anger and Impulse or Manic DisordersDisorders

Anger is often considered to be an impulse disorder, like IED, or part of mania as proposed by Kraeplin and Freud.

Do these disorder account for those with anger symptoms?

No.


Anger symptoms over lap the most with ODD Research indicates that When therapists are asked

to pick an externalized disorders that they are treating, and asked what best diagnosis or descriptor identifies the child, ODD, CD, ADHD, BPD or Anger problems. They rate “anger problem” the highest.

So We may want an ANGER diagnosis rather than ODD.

Anger Only

IED Only

Bipolar I Only

Bipolar II Only

ADD only

Any Substance DX

Anger & IED

Anger & Bipolar I

Anger & Bipolar II

Anger & ADD

Anger and Substance DX

0

50

100

150

200

250

300

350

Fre

qu

ency

Figure 3A. Diagnosis of Impulse Disorders & Anger, Out of 1774 Patients

N=315

Anger Only Anger & IED Anger & Bipolar I

Anger & Bipolar II

Anger & ADD Anger and Substance DX

0%

10%

20%

30%

40%

50%

60%

70%

Perc

en

tFigure 3. Anger Patients & Comorbid Impulse Disorders, N = 459.

N=315

Anger and IEDAnger and IED

Most people experience state anger when they behave aggressively.

Some people have moderate trait anger but explode and express anger aggressively when

they get angry.For these few with IED this may be an adequate

category.But most of those who meet criteria for IED are

angry.

Anger and IEDAnger and IED

IED is inadequate for most people with anger symptoms.

Most IED and aggressive clients have high trait anger when they aggress. Thus, they are

not adequately described by IED.

Anger and Emotional Anger and Emotional DisordersDisorders

What about other disorders of excess affect such as anxiety and mood or depressive disorders?

Do these disorders account for anger symptoms?

NO.

No Affetive Probllem

Anger Only Anxiety Only

Depression Only

Anger & Anxiety

Anger & Depression

Anxiety and Depression

All Three Emotions

50

100

150

200

250

300

350

400

Co

un

tFigure 4. Frequency of Emotional Disorders and Anger Symptoms & Comorbide Cases. N = 1774.

No Affetive Probllem

Anger Only Anxiety Only

Depression Only

Anger & Anxiety

Anger & Depression

Anxiety and Depression

All Three Emotions

0%

5%

10%

15%

20%

25%

Perc

en

tFigure 4A. Percent of Patietns with Emotional Disorders, Anger Problems & Comorbidity. N = 1774.

Anger Only Anger & Anxiety Anger & Depression All Three Emotions

Anger Anx Dep

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Perc

en

t

with and without Other Emotional Disorders, N = 459.

Figure 4B. Clients with Anger Symptoms

Anger and Emotional DisordersAnger and Emotional Disorders

Anger is comorbid more frequently with anxiety than depression, despite the focus on depression.

Anger symptoms occur more frequently with anxiety & depression.

Perhaps we need a disorder of excessive affect.Anger without other disturbed affect occurs less

frequently than anxiety and depression do alone, but still frequent enough to be a disorder in its own

right.The most common comorbid Anxiety Disorder is

not GAD or PTSD.It is Social Phobia.

Diagnostic Criteria for Anger Diagnostic Criteria for Anger Regulation and Expression DisorderRegulation and Expression Disorder

Either (1) or (2)1 Significant angry affect as indicated by frequent,

intense, or enduring anger episodes that have persisted for at least six-months. Two more of the following characteristics are present during or immediately following anger experiences:

Physical activation (e.g., increased heart rate, rapid breathing, muscle tension, stomach related symptoms, headaches)

Rumination that interferes with concentration, task performance, problem-solving, or decision-making


Cognitive distortions (e.g., biased attributions regarding the intentions of others; inflexible demanding view of others unwanted behaviors, code of conduct, or typical inconveniences; low tolerance for discordant events; condemnation or global rating of others who engage in perceived transgressions)

Ineffective communication

Brooding or withdrawal

Subjective distress (e.g., awareness of negative consequences associated with anger episodes, anger experiences perceived as negative, additional negative feelings such as guilt, shame, or regret follow anger episodes)


– 2 A marked pattern of aggressive/expressive behaviors associated with anger episodes. Expressive patterns are out of proportion to the triggering event. However, anger experiences need not be frequent, of high intensity, or of long duration. At least one of the following expressive patterns is consistently related to anger experiences:


Direct Aggression/Expression Aversive verbalizations (e.g., yelling, screaming, arguing nosily, criticizing,

using sarcasm, insulting) Physical aggression toward people (e.g., pushing, shoving, hitting, kicking,

throwing objects) Destruction of property Provocative bodily expression (negative gesticulation, menacing or

threatening movements, physical obstruction of others)

Indirect Aggression/Expression Intentionally failing to meet obligations or live up to others’ expectations Covertly sabotaging (e.g., secretly destroying property, interfering with task

completion, creating problems for others) Disrupting or negatively influencing others’ social network (e.g., spreading

rumors, gossiping; defamation, excluding others from important activities)

Diagnostic Criteria for AREDDiagnostic Criteria for ARED

B There is evidence of regular damage to social or vocational relationships due to the anger episodes or expressive patterns.

C The angry or expressive symptoms are not better accounted for by another mental disorder (e.g., Substance Use disorder, Bipolar Disorder, Schizophrenia, or a personality disorder) or medical condition.

Diagnostic Criteria for AREDDiagnostic Criteria for ARED

Three subtypes of ARED– Primarily Expressive. Aggressive moderate

anger. Same as IED. Perhaps we have found impulsively, moderately angry, non ruminative patients.

– Primarily Subjective High Anger with Anger-In only or non-confrontive aggression.

– Combined - High Anger and high aggression

Primarily Subjective Anger Primarily Subjective Anger SubtypeSubtype

Treat the resentment, and suspiciousness.Treat the hurt and easily bruised ego.This group holds their anger in a lot and

they need new assertiveness skills

Primarily Expressive Anger Primarily Expressive Anger SubtypeSubtype

Self control training and impulse control training to not respond aggressively when angered.

Assertiveness skills to replace aggression.

Combined Angry and Aggressive Combined Angry and Aggressive SubtypeSubtype

There may be two groups in here– Verbal– Confrontive aggressive– Non Confrontive aggressive– For the first coercion may be the motive and

treatment leads to acceptance of non control

Combined Angry and Aggressive Combined Angry and Aggressive SubtypeSubtype

For the second tension reduction may be the motive. Acceptance of the affect may be the primary treatment strategy

For the non confrontive and some confrontive clients REVENEG is the motive. Forgiveness is the treatment

Contact Ray DiGiuseppeContact Ray DiGiuseppe

Department of Psychology

St. John’s University

Jamaica, NY 11439

[email protected]

797p03 - using anger assessment in children and adolesncents

Documents