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Journal of Intellectual and Developmental Disability

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The Anger Management Project: A group intervention

for anger in people with physical and multiple
disabilities
a

Nick Hagiliassis , Hrepsime Gulbenkoglu , Mark Di Marco , Suzanne Young & Alan Hudson
a

Scope, Victoria, Australia

RMIT University, Victoria, Australia

Published online: 15 Jan 2014.

To cite this article: Nick Hagiliassis, Hrepsime Gulbenkoglu, Mark Di Marco, Suzanne Young & Alan Hudson (2005) The Anger
Management Project: A group intervention for anger in people with physical and multiple disabilities, Journal of Intellectual
and Developmental Disability, 30:2, 86-96
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Journal of Intellectual & Developmental Disability, June 2005; 30(2): 8696

The Anger Management Project: A group intervention for anger in

people with physical and multiple disabilities

NICK HAGILIASSIS1, HREPSIME GULBENKOGLU1, MARK DI MARCO1,

SUZANNE YOUNG1 & ALAN HUDSON2
Scope, Victoria, Australia, 2RMIT University, Victoria, Australia

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Abstract
Background This paper describes the evaluation of a group program designed specifically to meet the anger management
needs of a group of individuals with various levels of intellectual disability and/or complex communication needs.
Method Twenty-nine individuals were randomly assigned to an intervention group or a waiting-list comparison group. The
intervention comprised a 12-week anger management program, based on Novacos (1975) cognitive-behavioural
conceptualisation of anger, which incorporates adapted content and pictographic materials developed for clients with a
range of disabilities.
Results On completion of the program, clients from the intervention group had made significant improvements in their selfreported anger levels, compared with clients from the comparison group, and relative to their own pre-intervention scores.
Treatment effects were maintained at 4-month follow-up. In contrast, there was an absence of measured improvements in
quality of life.
Conclusions The results provide evidence for the programs effectiveness as an intervention for anger problems for
individuals with a range of disabilities.

Introduction
Anger is defined as a state of emotion that involves
varying intensities of feelings from aggravation and
annoyance to rage and fury (Spielberger, 1991).
Although anger is a normal emotion, it can become
problematic if it is expressed inappropriately, or if it
is experienced in excessive, intensive, or prolonged
forms, and if it results in impairment in personal
functioning. Poor anger control has been shown to
be an important determinant of aggressive and other
forms of challenging behaviour for people with an
intellectual disability (Black, Cullen, & Novaco,
1997; Kiernan, 1991). Anger expressed through
aggression can result in obvious negative outcomes
for the individual with a disability (e.g., restricted
opportunities, impaired social relationships, diminished self-esteem). The behavioural consequences of
anger can also present as a burden to families and
staff working in day and residential services, as well
as to the wider community. Even anger that is not
expressed through aggression, but rather through
passive means (e.g., insults, complaints, sarcasm,
intimidation), can have detrimental consequences
for the individual and others.

While prevalence rates for anger control problems

in people with a disability compared with people
without a disability are not firmly established, there
is evidence that people with disabilities present with
higher rates of anger control problems compared
with people without disabilities (Hill & Bruininks,
1984; Sigafoos, Elkins, Kerr, & Attwood, 1994;
Smith, Branford, Collacott, Cooper, & McGrother,
1996; Taylor, Novaco, Gillmer, & Thorne, 2002).
In establishing prevalence rates, researchers have
tended to examine rates of aggressive behaviour,
which is often mediated by anger (Taylor, 2002;
Taylor et al., 2002). In a survey of 2,277 people with
intellectual disability, Smith et al. (1996) observed
that 23% of males and 19% of females were reported
by carers as being physically aggressive, while in
another survey of 2,412 people, Sigafoos et al.
(1994) found 11% of the total population were
identified by service providers as exhibiting aggressive behaviour.
Having recognised that anger can present as a
significant problem for some people with disabilities,
practitioners have endeavoured to develop specialised anger management interventions for this
population. The few programs developed to date

Correspondence: Dr Nick Hagiliassis, Psychology Advisor, Scope, 177 Glenroy Road, Glenroy, Victoria 3046, Australia. E-mail: nhagiliassis@scopevic.org.au
ISSN 1366-8250 print/ISSN 1469-9532 online # 2005 Australasian Society for the Study of Intellectual Disability Inc.
DOI: 10.1080/13668250500124950

Downloaded by [Nanyang Technological University] at 14:07 17 June 2014

The Anger Management Project

(e.g., Benson, 1992; Gilmour, 1998; Howells,
Rogers, & Wilcock, 2000) have tended to adopt
approaches to intervention based on the seminal
work of Novaco (1975, 1986). Consistent with the
cognitive-behavioural view, Novaco argues that it is
an individuals appraisal of an event or situation that
mediates their emotional arousal and behavioural
response, and that determines whether or not they
are likely to feel angry and/or behave aggressively.
One of the foremost programs of this type is
Bensons (1992) Anger Management Training Program. In line with Novacos cognitive-behavioural
model of anger, Bensons program focuses on
self-instructional training, relaxation training, and
training in problem-solving skills.
One feature of programs such as that of Benson
(1992) is that they are generally targeted at
individuals with mild to moderate degrees of
intellectual disability. Adaptation of these methods
is needed for people whose cognitive limitations are
more severe in nature. Moreover, such programs are
not easily accessible to people with severe communication impairment, in particular those with expressive language difficulties. The heavy emphasis on the
need to contribute to group processes using varying
levels of verbal ability can be a barrier for people who
use nonverbal or augmentative communication
approaches. At a more extreme level, a feature of
some anger management programs has been the
screening out of prospective clients for group-based
anger management interventions on the basis that
they have difficulties in verbal communication,
particularly in terms of labelling feelings and emotions (Howells et al., 2000). Clearly, there is a
pressing need for anger management tools that are
tailored to the needs of people with various levels of
cognitive ability, but that are also more inclusive of
individuals with various degrees of verbal ability.
Additionally, there is a paucity of research on the
effectiveness of group programs for anger control
problems for people with cognitive disabilities.
There have been at least two evaluations of
Bensons (1992) program. The program was evaluated by Benson, Johnson Rice, and Miranti (1986),
who found that anger management training for 54
adults with mild to moderate intellectual disabilities
using a group format was associated with positive change on a variety of measures, including
self-reports and carers ratings of aggressive behaviour. In an attempt to replicate the findings of
Benson et al., King, Lancaster, Wynne, Nettleton,
and Davis (1999) evaluated the efficacy of the
Benson program with 11 adults with mild intellectual disabilities using a group format. Improvements
were evident on a range of measures of anger and

87

self-esteem. However, a limitation of both the King

et al. study and the Benson et al. study is the absence
of a comparison group; consequently, neither could
be confident that the effects were as a result of the
intervention. This is acknowledged by both groups
of researchers, with King et al. stating that a
direction for future research is for more controlled
investigations.
Gilmour (1998) reports the qualitative findings of
a pilot anger management program for 10 clients
presenting with mild to moderate intellectual
disability and challenging behaviours. Following
participation in a 14-week program that included
components on personal anger triggers, coping
strategies, assertiveness and communicatory confidence, client gain was noted through increases in the
use of communication, self-advocacy and assertiveness, and reductions in the severity and frequency of
challenging behaviours. However, although the
study provides initial qualitative evidence for the
effectiveness of this approach to challenging behaviour, the small sample size, the absence of a nontreatment group and the fact that no quantitative
results were reported mean that these data need to
be interpreted cautiously.
Howells et al. (2000) describe a 12-session program for 5 clients with mild to moderate intellectual
disabilities referred to a psychology clinic for
difficulties with aggression. The program covered a
range of topics, including the recognition of feelings,
identifying the physical and psychological signs of
anger, personal anger triggers, alternative thoughts
and attributions of the actions of others, and
teaching functional alternatives to aggression.
Although the authors attempted to include a number
of outcome measures (e.g., a self-esteem rating
scale) there was a lack of robust quantitative data
to indicate any potential effects of the training, a
limitation acknowledged by the authors themselves.
However, qualitative data collected through semistructured interviews indicated that all participants
felt more in control of their own anger on completion of the program.
Acknowledging the need for the development of
anger management programs for people with more
severe disabilities, Rossiter, Hunnisett, and Pulsford
(1998) developed a program targeted primarily
at people with moderate to severe intellectual
disabilities. This program incorporated elements
from Bensons (1992) program, but with a further
modified structure to tailor it to the needs of people
with more limited verbal ability and cognitive
capacity. Six people with moderate to severe
intellectual disabilities participated in 8 training
sessions. Based on qualitative data, the group

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N. Hagiliassis et al.

appeared to demonstrate that people with moderate

to severe intellectual disabilities are able to make use
of a simplified approach to anger management.
However, although the data were suggestive of
positive effects, the authors acknowledged that the
study was not subject to any kind of control, while
participants continued to receive additional individualised input (e.g., psychological), and there were
no robust data to objectively quantify reductions in
anger responses.
There are few treatment studies involving comparison groups with clients with intellectual disabilities. Rose, West, and Clifford (2000) examined a
group treatment program for individuals with mild
to moderate intellectual disabilities, comparing these
individuals to a similar group of individuals waiting
to participate. The program was similar to Rose
(1996), which used a modified Novaco approach,
but with additional individualised techniques. Five
groups were held over 2 years for between 6 and
9 participants, with a total of 25 people in the
intervention groups. Nineteen people participated in
a waiting-list control group, a significant number of
whom went on to participate in subsequent intervention groups. Measures administered included an
anger inventory and a depression inventory.
A reduction in measured levels of anger and
depression occurred after group treatment, with
treatment effects maintained at 6- and 12-month
follow-up. While this controlled study demonstrated significant reductions in expressed anger for
subjects receiving anger management training, a
limitation of this study is that it occurred without
randomisation.
Perhaps the most robustly conducted study to
date in this area emerges from Willner, Jones,
Tams, and Green (2002). In their randomised
controlled trial, 14 people with intellectual disabilities with anger management difficulties were
assigned to a treatment group and waiting-list
comparison group, with the treatment group participating in 9 sessions of a cognitive-behaviouralbased anger management program. The program
included content relating to the triggers that evoke
anger, physiological and behavioural components of
anger, behavioural and cognitive strategies to avoid
the build-up of anger and for coping with angerevoking situations, and acceptable ways of expressing anger. The intervention was evaluated by
means of two anger inventories, which were
completed by both clients and carers. Individuals
in the treatment group improved on both self- and
carer-ratings, relative to their own pre-intervention
scores, and to the comparison group post-intervention. Of note, the degree of improvement was

strongly correlated with IQ. However, although this

study is perhaps the first randomised controlled trial
comparing treatment and non-treatment groups, the
extent to which the results may be generalised is
limited because of the small numbers involved
(N 5 14). Additionally, beyond reporting that all
clients experienced mild intellectual disabilities,
there is little information given about other client
characteristics, such as primary communication
mode (e.g., verbal/nonverbal). A final limitation is
that detail of the programs plan and content is not
presented, making it difficult for other researchers
and practitioners to replicate.
Purpose of the study
The review of the literature demonstrates that while
there have been some attempts to develop programs
for individuals with disabilities with anger management problems, there are few such programs to date.
Of the few developed, most are targeted at
individuals with mild to moderate intellectual disability, and with various levels of verbal ability.
There is clearly a need to develop anger management programs that are accessible to a wider range of
individuals with disabilities, and specifically, those
with more limited cognitive skills and/or more
complex communication needs. Perhaps the
only study to focus on people with more severe
intellectual disabilities is that of Rossiter et al.
(1998), but this study was not subject to rigorous
evaluation.
Another issue is the overall lack of robust data on
the effectiveness of group anger management
programs for individuals with disabilities. Many
studies suffer from methodological problems, such
as the absence of comparison groups, the use of
small samples, and the lack of reliable, quantitative
data, that makes consolidation and interpretation of
findings difficult. Willner et al. (2002) provide
perhaps the first randomised controlled trial of an
anger management intervention in individuals with
intellectual disabilities. However, their study
involved only small numbers of participants, while
the population under investigation was individuals
with mild intellectual disabilities.
Following on from these issues, the present study
examines the effectiveness of a 12-session anger
management program (Gulbenkoglu & Hagiliassis,
2002) for individuals with a range of levels
of
intellectual
disability
and/or
complex
communication needs. The programs effectiveness
was evaluated using a randomised controlled trial of
29 individuals with disabilities with anger control
difficulties.

89

The Anger Management Project

Method

Table 1. Client characteristics

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Participants
Following ethics approval, all individuals involved
in the project were recruited from Scope.1 A flier
was distributed seeking expressions of interest, from
which 34 referrals were received. An initial interview with a psychologist involved with the project
was conducted to confirm that an individual was
presenting with a clinically significant anger problem and that they would engage in and benefit
from involvement in a group program. Four
referrals were deemed unsuitable. In two cases,
this was because the presenting issue was not
assessed as being a core problem in anger control,
while in the other two cases, the individuals
ultimately had reservations about participation in
a group and expressed a preference for individualised treatment. A referral to individualised anger
management counselling was arranged in these
circumstances.
Clients were based either in the North West (NW)
or South East (SE) Melbourne Metropolitan
Region. It was therefore decided to establish two
intervention groups, one in each of these regions, to
be delivered simultaneously. The 30 clients were
allocated randomly to an immediate intervention
group or a waiting-list comparison group, using
regional locality as a stratification variable. Within
each region, clients were assigned by simple random
allocation to an intervention group or a comparison
group, with males and females allocated alternately
to ensure an even spread of gender. An individual
who was not involved in the study and who was
blinded to the identity of the clients performed the
randomisation. For the NW region, the intervention
and comparison groups were assigned 7 participants
each, while for the SE region, each group was
assigned 8 participants. It eventuated that one client
in the SE intervention group withdrew from the
study (citing difficulties with transportation, as well
as reduced motivation for participation in the group,
as a reason), resulting in 7 members in that
intervention group as well. Hence, the data of 29
individuals were retained. Note that although
individuals in the comparison group did not receive
the intervention, they continued to have access to
their existing level of support (ranging from no
formal support to individual counselling).
Client characteristics are presented in Table 1. Of
note, a number of clients who used a means other
than speech as their primary form of communication were included in the study. These clients
employed a range of nonverbal communication
methods, including electronic communication

Intervention
(n 5 14)
Characteristic
Male
Female
No intellectual
disabilitya
Borderline intellectual
disabilityb
Mild intellectual
disabilityc
Moderate intellectual
disabilityd
Severe intellectual
disabilitye
Cerebral palsy
Visual disability
Psychiatric disability
Verbal
communication
Nonverbal
communication
Uses wheelchair
Ambulant

Comparison
(n 5 15)

Number Percentage Number Percentage

7
7
0

50%
50%
0%

9
6
1

60%
40%
7%

36%

13%

7%

7%

29%

27%

29%

47%

14
1
0
10

100%
7%
0%
71%

14
2
1
11

93%
14%
7%
73%

29%

27%

10
4

71%
29%

9
6

60%
40%

a
PPVT-III Standard Score .80, bPPVT-III Standard Score
7180, cPPVT-III Standard Score 6170, dPPVT-III Standard
Score 5160, ePPVT-III Standard Score ,51.

devices, communication boards, as well as sign,

gesture and facial expressions.
Assessments
Four weeks prior to the commencement of the
program, clients were administered Section A of the
Novaco Anger Scale (NAS: Novaco, 1994) designed
to measure the cognitive, arousal and behavioural
aspects of anger. The NAS has been found to have a
high internal (.95) and testretest (.88) reliability as
well as sound validity (Novaco, 1994). There were
48 questions in total. Participants responded along a
3-point scale (1 5 yes, 2 5 sometimes, 3 5 no) reflecting their level of agreement, with a minimum
possible score of 48 and a maximum of 144.
Participants provided their responses verbally, or
by pointing to a pictograph for yes, no or sometimes.
Minor modifications were made to some of the
items, so as to be more appropriate to a group of
clients with physical disabilities (e.g., adapting the
item I walk around in a bad mood to I move around in a
bad mood), while maintaining the integrity of the
meaning of the original item.
Clients were also administered the Outcome Rating
Scale (ORS: Miller & Duncan, 2000), designed to
measure change in a persons quality of life as a
result of a therapeutic intervention. Participants

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90

N. Hagiliassis et al.

were asked four questions: How do you feel about life

overall? How do you feel about yourself ? How do you feel
about your family and friends? and How do you feel
about your day service/workplace? Minor modifications
were made to the original ORS questions so as to be
more contextually relevant to the client group under
investigation in the present study. For each question,
participants rated themselves using a simple 5-point
visual scale (1 5 really bad, 2 5 bad, 3 5 OK,
4 5 good, 5 5 really good), with a minimum possible
score of 5 and maximum of 20. Because the ORS
requires only a simple pointing response, it offers
some promise for the measurement of quality of life
in people with disabilities, and hence was selected
for use in the present study.
Clients were generally able to respond to the NAS
and ORS assessments adequately. For the few items
that clients were uncertain of (e.g., when items
tapped domains of life they had not experienced),
these items were excluded from the scoring and a
pro-rated total score was calculated. The NAS and
ORS assessments were also administered postintervention, and at a 4-month follow-up assessment. Of note, blind assessment at each of these
time points could not be achieved. In an attempt to
attenuate this issue, client assessments were conducted by a psychologist who was not a facilitator for
the group the client attended, and by assessors who
did not have an ongoing professional relationship
with or detailed knowledge of the client.
Finally, clients were administered the Peabody
Picture Vocabulary Test (PPVT-III: Dunn &
Dunn, 1997) and the Ravens Coloured Progressive
Matrices (CPM: Raven, Raven, & Court, 1998) as a
measure of receptive vocabulary and nonverbal
reasoning abilities respectively. Both the PPVT-III
and CPM have particular utility as assessment
tools for individuals with complex communication needs because they do not require a verbal
response.
The intervention
The intervention delivered was The Anger
Management Training Package (Gulbenkoglu &
Hagiliassis, 2002), a new anger management package designed for individuals with a range of levels of
intellectual disability and/or complex communication needs. The program is also developed to reflect
themes and content relevant to the lives of people
with physical disabilities, and incorporates adapted
activities and techniques (e.g., modified relaxation)
for this group.
The theoretical framework adopted in the package
draws on Novacos (1975) cognitive-behavioural

conceptualisation of anger, which has also been

utilised in other programs (e.g., Benson, 1992).
Physiological components of anger are addressed
through training in the use of relaxation techniques
(e.g., progressive muscle relaxation, visualisation,
deep breathing), but using modified procedures for
people whose physical abilities, verbal abilities and
capacity for understanding complex concepts are
compromised. The cognitive components of anger
are addressed through cognitive restructuring.
Although cognitive restructuring has been an intrinsic feature of various anger management packages
for people with intellectual disabilities (e.g., Benson,
1992; Taylor et al., 2002; Rossiter, et al., 1998), the
extent to which clients with limitations in cognition
can benefit from such an approach is not clear.
Taylor et al. (2002) and others (Rose, 1996; Rose
et al., 2000; Whitaker, 2001) suggest that the
cognitive components of anger interventions may
have limited efficacy in clients with intellectual
disabilities, while non-cognitive components (e.g.,
relaxation) may have greater benefit. Nevertheless,
given the central role of cognition as a mediator of
anger, a cognitive restructuring component could
not have been ignored. Similar to Bensons (1992)
program, training in self-instruction is included, with
the aim being to increase the use of calm thoughts
and reduce angry thoughts. The behavioural
components of anger are addressed through
problem-solving and assertiveness skills training. A
standard four-step problem-solving model was used,
that involved (a) defining the problem, (b) looking
for possible solutions, (c) implementing the solution
most likely to prove effective, and (d) evaluating the
success of that solution (King et al., 1999; Rose et al.,
2000). A standard model for teaching assertiveness
training was used, that included (a) identifying
personal rights and responsibilities, (b) describing
nonassertive behaviour and its consequences, and
(c) exploring the positive consequences of behaving
assertively (Holbrook Freeman & Freeman Adams,
1999).
A prominent feature of the package is an emphasis
on pictographic symbols, functioning as a visual
learning aid for clients with cognitive limitations, as
well as an augmentative communication medium for
clients with complex communication needs. The
importance of pictographs as an adjunct to learning
is highlighted by Turk and Francis (1990), who
found that information presented to individuals with
intellectual disabilities in the form of instruction
without any accompanying visual aids was rapidly
forgotten. Similarly, active learning techniques, roleplay and repetition were emphasised to facilitate
skills acquisition.

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The Anger Management Project

The program comprises 12 weekly sessions of 2
hours duration, including a 15-minute break. Each
session is fully scripted and follows a standard
format, beginning with a review of skills learned
during the previous session, followed by an introduction and explanation of the major session topic
and then addressing the key learning aims for that
session. The key elements of the content of the 12
anger management group sessions are presented in
Table 2.
As two intervention groups were conducted in the
present study, slight variations in focus, pace and
emphasis may have occurred across the two groups,
given the realities of working with different groups
of participants. However, this was not felt to be a
significant issue and was attenuated by the standardised nature of the package. Sessions were facilitated
by two psychologists, a male and a female in the case
of the NW intervention group, and the same female,
along with another female, in the case of the SE
intervention group. Two carers attended the SE
intervention group, and they were encouraged to

91

participate in that group, and to support clients

other than their own with activities and role-plays. A
total of 11 out of the 14 clients in the intervention
groups attended all 12 sessions, while two clients
attended 11 sessions, and one client attended 10.
Results
PPVT-III, CPM and age data are presented in
Table 3. Univariate analyses of variance revealed
there were no significant differences between the
intervention groups (n 5 14) and comparison groups
(n 5 15) on PPVT-III and CPM measures, or on
age. Of note, these data indicate that both the
intervention and comparison groups were inclusive
of individuals with a range of cognitive abilities.
Although not directly equivalent to IQ, performances on these assessments suggest the sample
was inclusive not only of people with mild intellectual disabilities, but also those with moderate to
severe intellectual disabilities. PPVT-III standard
scores ranged from 40 to 79 for the intervention

Table 2. Content of the 12 anger management group sessions

Session

Topic

Key learning objectives

N
N
N
N
N
N
N
N
N
N

Introduction to anger management

Introduction to anger management

Learning about feelings and anger

Learning about helpful and unhelpful ways

Learning to relax

Learning to relax

Learning to think calmly

Learning to think calmly

Learning to think calmly

10

Learning to handle problems

11

Learning to speak up for ourselves

N
N
N

12

Putting it all together

N
N

N
N
N
N
N
N
N
N
N
N
N
N
N
N

introduce participants and conduct ice-breaker exercise

present rules of group work
introduce concept of anger and anger management
further explore concept of anger and anger management
conduct brief self-assessment of anger
present an overview of material to be covered in program
identify and label common feelings
examine triggers that evoke anger
explore the cognitive, physiological and emotional correlates of anger
distinguish between helpful (adaptive) and unhelpful (maladaptive) coping
strategies
have participants identify their own helpful and unhelpful coping strategies
introduce concept of relaxation and its role in anger management
conduct a range of four modified relaxation techniques: deep breathing, selfaffirmation, visualisation and slow-counting
conduct a modified progressive muscle relaxation technique
explore lifestyle changes to enhance relaxation
examine the difference between calm thoughts and angry thoughts
explore the role of angry thoughts in mediating feelings and behaviour
introduce concept of self-coping statements
develop individualised self-coping statements
examine common thinking errors
explore other healthy thinking strategies
explore a range of problems experienced and how these impact on anger
introduce a four-step problem-solving framework
have participants apply problem-solving framework to a recent problem
experienced
examine the difference between passive, aggressive and assertive behaviours
explore a range of practical techniques for assertive behaviour
have participants identify assertive behaviours for a recent anger-evoking
situation
have participants develop their own personal anger management plan
complete individualised evaluation

92

N. Hagiliassis et al.

Table 3. Age, PPVT-III and CPM data for intervention and comparison groups
Intervention (n 5 14)

Age (years)
PPVT-III (standard score)
CPM (age-equivalent score)

Mean

SD

Min.

Max.

Mean

SD

Min.

Max.

44.93
60.00
6.89

13.04
14.25
1.80

28
40
5

74
79
11

43.57
56.77
7.31

12.76
18.11
2.48

26
40
5

73
97
12

groups and 40 to 97 for the comparison groups.

CPM age-equivalent scores ranged from 5 to 11
years in the intervention groups and 5 to 12 years in
the comparison groups.

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Comparison (n 5 15)

Novaco Anger Scale (NAS) results

The overall NAS data are presented in Fig. 1. Note
that an increase in mean NAS scores is associated
with an increase in anger control. A repeated
measures ANOVA with NAS scores as the dependent measure reveals a non-significant main effect
for treatment condition (intervention group, comparison group), a significant main effect for time
of assessment (pre-intervention, post-intervention,
4-month follow-up), F(2,26) 5 5.31, p,.05, and
a significant treatment condition 6 time of assessment interaction effect, F(2,26) 5 4.87, p,.05.
Closer inspection of this interaction effect reveals
that there was no significant difference between the
mean NAS scores of the intervention groups
(M 5 80.79, SD 5 18.04) and comparison groups

Figure 1. NAS data for intervention and comparison groups.

(M 5 80.01, SD 5 22.02) at pre-intervention.

At post-intervention, individuals from the intervention groups had achieved a higher NAS score
on average (M 5 97.36, SD 5 21.27) compared
with individuals from the comparison groups
(M 5 81.13, SD 5 18.85), a statistically significant
difference, t(27) 5 2.18, p,.05. A statistically
significant difference was maintained between the
intervention groups (M 5 100.86, SD 5 24.47) and
comparison groups (M 5 80.33, SD 5 20.10) at
4-month follow-up, t(27) 5 2.48, p,.05.
Within the intervention groups, there was an
increase in the mean NAS scores from 80.79
(SD 5 18.04) at pre-intervention, to 97.36
(SD 5 21.27) at post-intervention, a statistically
significant result, t(13) 5 3.34, p,.01. The difference in mean NAS scores between pre-intervention
and 4-month follow-up (M 5 100.86, SD 5 24.47)
was also statistically significant, t(13) 5 3.80, p,.01.
NAS scores at post-intervention and at 4-month
follow-up did not differ significantly for the intervention groups. In contrast, the NAS scores for the

The Anger Management Project

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comparison groups over the same time periods

remained relatively stable, from 80.01 (SD 5
22.02) at pre-intervention, to 81.13 (SD 5 18.85)
at post-intervention and 80.33 (SD 5 20.10)
at 4-month follow-up, with none of these differences proving significant. Collectively, these results
indicate an improvement in anger control as a
result of participation in the intervention groups.
Clients in the intervention group improved relative
to the comparison group at post-intervention, and
relative to their own pre-intervention scores, with
these improvements maintained at 4-month followup.
Outcome Rating Scale (ORS) results
The ORS data are presented in Fig. 2. A repeated
measures ANOVA with ORS scores as the dependent measure reveals a non-significant main effect
for both treatment condition and time of assessment,
as well as a non-significant treatment condition 6
time of assessment interaction effect. Although
individuals from the intervention groups had slightly
higher ORS mean scores relative to the comparison
groups at post-intervention and at 4-month followup, these differences were non-significant.
Therefore, the data do not demonstrate reliably that
improvements in quality of life emerged as a result of
the intervention.

Figure 2. ORS data for intervention and comparison groups.

93

Relationship of improvement in anger control

to other factors
The overall improvement shown by clients in the
intervention group (anger level change, calculated as
the difference between NAS scores at pre-intervention and post-intervention) correlated significantly
with CPM performance (r 5 2.56, p,.05), whereas
the correlation with PPVT-III performance
(r 5 2.21) was non-significant. These findings suggest an association between improvements in anger
and level of nonverbal reasoning abilities, but not
with level of receptive vocabulary. A linear regression
analysis (see Table 4) was undertaken to examine the
contribution of the variables of age, gender, primary
mode of communication, CPM performance and
PPVT-III performance. This analysis reveals the
only variable to account for significant variance in
improvements in anger was CPM performance.
Conversely, the variables of age, gender, primary
mode of communication and PPVT-III performance
did not contribute significantly to changes in anger
levels for the intervention group.
Discussion
The research demonstrates that individuals who
participated in an intervention group showed relative
improvements in self-reported levels of anger
between pre- and post-intervention, with treatment

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N. Hagiliassis et al.

Table 4. Results of multiple linear regression showing the

relationship of change in anger level to other variables
Variables

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Model summary
CPM score
PPVT-III score
Age
Gender
Primary communication
mode

R2 R2 change
.309

.309

Beta

Significance

2.556
2.556
2.094
2.471
2.432
.391

.039
.039
.718
.109
.081
.120

effects maintained at 4-month follow-up. In contrast, anger levels of individuals from the comparison
groups remained relatively stable over the same
period. From this, it may be concluded that the
therapeutic approach examined in the present study
was successful in reducing levels of anger in
individuals with a range of levels of intellectual
disability and complex communication needs. As
already indicated, CPM and PPVT-III scores confirm that individuals representative of a range of
cognitive abilities, including those with moderate to
severe intellectual disabilities, were sampled in the
study. Additionally, there was a spread of communication abilities sampled, ranging from clients who
used speech as their primary form of communication, to clients who employed a range of nonverbal
communication methods, such as electronic communication devices and communication boards.
Given the paucity of specialised anger management
programs for individuals with disabilities with a
range of cognitive and/or communication abilities,
the finding is a welcome outcome. Effectively,
the finding extends the range of evidence-based
resources available to practitioners for delivering
interventions for individuals with anger control
issues and disabilities.
In contrast to observed improvement in anger
levels, there was an absence of measured changes in
quality of life for the intervention group compared
with the comparison group. Although there was no a
priori reason for expecting a relationship to emerge
between participation in an anger intervention group
and improvements in quality of life, the potential
finding of such a relationship would have
nevertheless been a positive outcome. However, this
was not the case. One possibility is that the benefits
of the intervention are restricted to improvements in
anger control, rather than improvements in other
psychological domains, such as quality of life.
Another possibility is that the measure itself was
not robust for this client group. Despite its selection
as a tool with promising utility for the assessment of
treatment outcomes for individuals with disabilities,

there are no specific psychometric data available on

the ORS and its use with people with disabilities.
Further investigation of the link between anger and
quality of life in individuals with disabilities would
seem a useful direction for future research, as would
the accumulation of further psychometric data on
tools used to measure these constructs.
The present study has a number of methodological strengths. Foremost, the study was a randomised
controlled trial of an anger management intervention
in individuals with disabilities. The only other
identified randomised controlled trial is that of
Willner et al. (2002), who found similarly that
clients in their intervention group showed improvements in anger control relative to their own preintervention scores, and to their comparison group
post-intervention. However, the results of the present study potentially have greater generalisability as
a larger sample was used (N 5 29) compared with
the Willner et al. (2002) study (N 5 14). Clearly, a
focus for future research examining the efficacy of
anger management training programs for individuals
with disabilities should be more controlled investigations with larger sample numbers so that researchers
may have greater confidence in the inferences they
draw from their findings. Other strengths of the
present study, that would also appear to be valuable
inclusions for future research, are the reporting of
robust data in order to objectively quantify the
effects of the intervention, the presentation of client
characteristics in order to aid the interpretation of
findings, and the provision of adequate reference to
the content of the program in order to allow its
replication elsewhere.
Despite the aforementioned strengths, there are
also a number of potential limitations of the study.
Even though the research was a randomised controlled study, the randomised controlled nature of
the research may have been further enhanced by the
inclusion of a second comparison group, one which
was involved in a placebo group activity. This would
have provided the researchers with even greater
confidence that the improvements seen were as a
result of the intervention, as opposed to being an
artefact of participation in a group. Additionally,
although the study involved larger numbers of
participants than a previous randomised controlled
trial, the sample size used in the present study is by
no means exhaustive, and a direction for future
research would be replication with a larger sample.
Another potential limitation of the present study is
the absence of carer reports as an external validation
of the improvements in self-reported levels of anger
of clients in the intervention group. This was a
conscious decision on the part of the researchers

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The Anger Management Project

who, in line with client-centred practice, were
interested in being guided by the clients own
perception of their anger and its impact.
Notwithstanding this position, qualitative data collected through informal discussions indicated that
many carers felt participants were more in control of
their own anger on completion of the program. The
only exception to this was a carer for a client who
showed a deterioration in her anger control following
the program; this carer identified an exacerbation of
challenging behaviours for that client. While it would
seem useful for researchers to consider the question
of concurrent validation of clients self-reports of
anger, such as through the use of carer reports, the
decision should also be considered in the context of
client-centred practice.
Another question concerns the role of carers in the
program. To recapitulate, in addition to the two
facilitators, two carers participated in one of the
intervention groups. It is unclear what the impact of
introducing this element into the treatment process
was since no objective data were collected on this
factor. However, anecdotal observations suggest that
the inclusion of carers had a positive impact on client
outcomes overall. Beyond carers providing practical
assistance with the delivery of activities and roleplays, they appeared to play a valuable role in terms
of ensuring that the skills learnt in the context of a
group program were generalised across other settings, such as home, day service or work settings.
Along a similar line, evidence for the role of carers
in supporting skill generalisation is presented by
Willner et al. (2002), who noted that clients who
achieved the best outcomes were those accompanied
to the group by carers. Additionally, it appeared that
through their involvement with the program, carers
became more conversant with anger management
techniques, building on their capacity to work
effectively with clients with anger management
issues in the future. As pointed out also by Rose
et al. (2000), a direction for future research would be
to examine the influence of carers in producing and
maintaining change.
Additionally, while the results of the research
provide reliable evidence of the effectiveness of the
program in reducing self-reported levels of anger in
people with disabilities, precisely which elements of
the program were most responsible for producing
this change is unclear. The techniques that appeared
to be most useful were those reflecting the physiological (e.g., relaxation) and behavioural (e.g.,
problem-solving) components of the program. In
contrast, participants appeared to have more difficulty with the cognitive elements of the program.
This opinion has also been expressed by others

95

investigating similar programs (e.g., Rose et al.,

2000; Taylor et al., 2002; Willner et al., 2002), who
acknowledge that the cognitive components of such
programs are perhaps the most difficult to employ
with individuals with intellectual disability. Further
research is required to determine which of the
physiological, behavioural and cognitive components
of the program, or combinations thereof, are more
responsible for producing change.
Another interesting finding was a significant
negative correlation between CPM performance
and change in anger scores demonstrated by
participants from the intervention groups. This
result suggests that individuals with more significant
nonverbal reasoning deficits showed greater
improvements in anger control as a result of the
intervention, although it is important to emphasise
that clients with higher level nonverbal skills also
benefited from the program. The reasons for this
finding are not entirely clear, but the possibility
remains that some aspects of the program (e.g.,
pictographic materials, pace) may have been more
suited to individuals functioning in the lower range
of nonverbal abilities. The result is in contrast to the
findings of Willner et al. (2002), who found a nonsignificant correlation between nonverbal IQ and
anger outcomes for their intervention group. While it
is difficult to ascertain the source of these inter-study
variations, possible contributing factors include
differences in participant characteristics, as well as
differences in the actual anger management programs evaluated by each investigation. On an
associated matter, a somewhat perplexing result is
the observation of a significant correlation between
treatment outcomes for the intervention group and
performance on the CPM, but a non-significant
correlation between outcome and performance on
the PPVT-III. A regression analysis confirmed that
reasoning ability, as assessed using the CPM, was a
significant predictor of improvement, while receptive
vocabulary, as assessed using the PPVT-III, did not
contribute substantially to group outcomes. It is
possible that the programs emphasis on visual and
active learning techniques meant that nonverbal
reasoning skills were more likely to influence
intervention outcomes compared with receptive
vocabulary. However, this is a tentative hypothesis
insofar as the cognitive factors that underpin
successful outcomes in anger management programs
are poorly understood. Further research is required
to explicate these relationships.
In conclusion, the present study provides reliable
evidence of the effectiveness of this anger management intervention for individuals with a range
of levels of intellectual disability and/or complex

96

N. Hagiliassis et al.

communication needs. Beyond reinforcing the usefulness of specialised anger management programs as
interventions for individuals with disabilities, the
present study serves to highlight the importance of
continued research in the area, using a robust
research methodology. Through expanding the evidence base, practitioners will have greater confidence
in delivering interventions in the area, ultimately
making a substantial difference in the lives of clients
with disabilities with anger support needs.

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Author note
This research was considered and approved by the
Human Research Ethics Committee at RMIT
University.
Note
1 Scope is an organisation providing services to over 3,500
children and adults with physical and multiple disabilities in
Victoria, Australia.

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