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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 self-
reported 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.
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
The Anger Management Project 87
(e.g., Benson, 1992; Gilmour, 1998; Howells, self-esteem. However, a limitation of both the King
Rogers, & Wilcock, 2000) have tended to adopt et al. study and the Benson et al. study is the absence
approaches to intervention based on the seminal of a comparison group; consequently, neither could
work of Novaco (1975, 1986). Consistent with the be confident that the effects were as a result of the
cognitive-behavioural view, Novaco argues that it is intervention. This is acknowledged by both groups
an individuals appraisal of an event or situation that of researchers, with King et al. stating that a
mediates their emotional arousal and behavioural direction for future research is for more controlled
response, and that determines whether or not they investigations.
are likely to feel angry and/or behave aggressively. Gilmour (1998) reports the qualitative findings of
One of the foremost programs of this type is a pilot anger management program for 10 clients
Bensons (1992) Anger Management Training Pro- presenting with mild to moderate intellectual
gram. In line with Novacos cognitive-behavioural disability and challenging behaviours. Following
model of anger, Bensons program focuses on participation in a 14-week program that included
self-instructional training, relaxation training, and components on personal anger triggers, coping
training in problem-solving skills. strategies, assertiveness and communicatory confi-
One feature of programs such as that of Benson dence, client gain was noted through increases in the
(1992) is that they are generally targeted at use of communication, self-advocacy and assertive-
individuals with mild to moderate degrees of ness, and reductions in the severity and frequency of
intellectual disability. Adaptation of these methods challenging behaviours. However, although the
is needed for people whose cognitive limitations are study provides initial qualitative evidence for the
more severe in nature. Moreover, such programs are effectiveness of this approach to challenging beha-
not easily accessible to people with severe commu- viour, the small sample size, the absence of a non-
nication impairment, in particular those with expres- treatment group and the fact that no quantitative
sive language difficulties. The heavy emphasis on the results were reported mean that these data need to
need to contribute to group processes using varying be interpreted cautiously.
levels of verbal ability can be a barrier for people who Howells et al. (2000) describe a 12-session pro-
use nonverbal or augmentative communication gram for 5 clients with mild to moderate intellectual
approaches. At a more extreme level, a feature of disabilities referred to a psychology clinic for
some anger management programs has been the difficulties with aggression. The program covered a
screening out of prospective clients for group-based range of topics, including the recognition of feelings,
anger management interventions on the basis that identifying the physical and psychological signs of
they have difficulties in verbal communication, anger, personal anger triggers, alternative thoughts
particularly in terms of labelling feelings and emo- and attributions of the actions of others, and
tions (Howells et al., 2000). Clearly, there is a teaching functional alternatives to aggression.
pressing need for anger management tools that are Although the authors attempted to include a number
tailored to the needs of people with various levels of of outcome measures (e.g., a self-esteem rating
cognitive ability, but that are also more inclusive of scale) there was a lack of robust quantitative data
individuals with various degrees of verbal ability. to indicate any potential effects of the training, a
Additionally, there is a paucity of research on the limitation acknowledged by the authors themselves.
effectiveness of group programs for anger control However, qualitative data collected through semi-
problems for people with cognitive disabilities. structured interviews indicated that all participants
There have been at least two evaluations of felt more in control of their own anger on comple-
Bensons (1992) program. The program was eval- tion of the program.
uated by Benson, Johnson Rice, and Miranti (1986), Acknowledging the need for the development of
who found that anger management training for 54 anger management programs for people with more
adults with mild to moderate intellectual disabilities severe disabilities, Rossiter, Hunnisett, and Pulsford
using a group format was associated with posi- (1998) developed a program targeted primarily
tive change on a variety of measures, including at people with moderate to severe intellectual
self-reports and carers ratings of aggressive beha- disabilities. This program incorporated elements
viour. In an attempt to replicate the findings of from Bensons (1992) program, but with a further
Benson et al., King, Lancaster, Wynne, Nettleton, modified structure to tailor it to the needs of people
and Davis (1999) evaluated the efficacy of the with more limited verbal ability and cognitive
Benson program with 11 adults with mild intellec- capacity. Six people with moderate to severe
tual disabilities using a group format. Improvements intellectual disabilities participated in 8 training
were evident on a range of measures of anger and sessions. Based on qualitative data, the group
88 N. Hagiliassis et al.
appeared to demonstrate that people with moderate strongly correlated with IQ. However, although this
to severe intellectual disabilities are able to make use study is perhaps the first randomised controlled trial
of a simplified approach to anger management. comparing treatment and non-treatment groups, the
However, although the data were suggestive of extent to which the results may be generalised is
positive effects, the authors acknowledged that the limited because of the small numbers involved
study was not subject to any kind of control, while (N 5 14). Additionally, beyond reporting that all
participants continued to receive additional indivi- clients experienced mild intellectual disabilities,
dualised input (e.g., psychological), and there were there is little information given about other client
no robust data to objectively quantify reductions in characteristics, such as primary communication
anger responses. mode (e.g., verbal/nonverbal). A final limitation is
There are few treatment studies involving com- that detail of the programs plan and content is not
parison groups with clients with intellectual disabil- presented, making it difficult for other researchers
ities. Rose, West, and Clifford (2000) examined a and practitioners to replicate.
group treatment program for individuals with mild
to moderate intellectual disabilities, comparing these
Purpose of the study
individuals to a similar group of individuals waiting
to participate. The program was similar to Rose The review of the literature demonstrates that while
(1996), which used a modified Novaco approach, there have been some attempts to develop programs
but with additional individualised techniques. Five for individuals with disabilities with anger manage-
groups were held over 2 years for between 6 and ment problems, there are few such programs to date.
9 participants, with a total of 25 people in the Of the few developed, most are targeted at
intervention groups. Nineteen people participated in individuals with mild to moderate intellectual dis-
a waiting-list control group, a significant number of ability, and with various levels of verbal ability.
whom went on to participate in subsequent inter- There is clearly a need to develop anger manage-
vention groups. Measures administered included an ment programs that are accessible to a wider range of
anger inventory and a depression inventory. individuals with disabilities, and specifically, those
A reduction in measured levels of anger and with more limited cognitive skills and/or more
depression occurred after group treatment, with complex communication needs. Perhaps the
treatment effects maintained at 6- and 12-month only study to focus on people with more severe
follow-up. While this controlled study demon- intellectual disabilities is that of Rossiter et al.
strated significant reductions in expressed anger for (1998), but this study was not subject to rigorous
subjects receiving anger management training, a evaluation.
limitation of this study is that it occurred without Another issue is the overall lack of robust data on
randomisation. the effectiveness of group anger management
Perhaps the most robustly conducted study to programs for individuals with disabilities. Many
date in this area emerges from Willner, Jones, studies suffer from methodological problems, such
Tams, and Green (2002). In their randomised as the absence of comparison groups, the use of
controlled trial, 14 people with intellectual disabil- small samples, and the lack of reliable, quantitative
ities with anger management difficulties were data, that makes consolidation and interpretation of
assigned to a treatment group and waiting-list findings difficult. Willner et al. (2002) provide
comparison group, with the treatment group parti- perhaps the first randomised controlled trial of an
cipating in 9 sessions of a cognitive-behavioural- anger management intervention in individuals with
based anger management program. The program intellectual disabilities. However, their study
included content relating to the triggers that evoke involved only small numbers of participants, while
anger, physiological and behavioural components of the population under investigation was individuals
anger, behavioural and cognitive strategies to avoid with mild intellectual disabilities.
the build-up of anger and for coping with anger- Following on from these issues, the present study
evoking situations, and acceptable ways of expres- examines the effectiveness of a 12-session anger
sing anger. The intervention was evaluated by management program (Gulbenkoglu & Hagiliassis,
means of two anger inventories, which were 2002) for individuals with a range of levels
completed by both clients and carers. Individuals of intellectual disability and/or complex
in the treatment group improved on both self- and communication needs. The programs effectiveness
carer-ratings, relative to their own pre-intervention was evaluated using a randomised controlled trial of
scores, and to the comparison group post-interven- 29 individuals with disabilities with anger control
tion. Of note, the degree of improvement was difficulties.
The Anger Management Project 89
were asked four questions: How do you feel about life conceptualisation of anger, which has also been
overall? How do you feel about yourself ? How do you feel utilised in other programs (e.g., Benson, 1992).
about your family and friends? and How do you feel Physiological components of anger are addressed
about your day service/workplace? Minor modifications through training in the use of relaxation techniques
were made to the original ORS questions so as to be (e.g., progressive muscle relaxation, visualisation,
more contextually relevant to the client group under deep breathing), but using modified procedures for
investigation in the present study. For each question, people whose physical abilities, verbal abilities and
participants rated themselves using a simple 5-point capacity for understanding complex concepts are
visual scale (1 5 really bad, 2 5 bad, 3 5 OK, compromised. The cognitive components of anger
4 5 good, 5 5 really good), with a minimum possible are addressed through cognitive restructuring.
score of 5 and maximum of 20. Because the ORS Although cognitive restructuring has been an intrin-
requires only a simple pointing response, it offers sic feature of various anger management packages
some promise for the measurement of quality of life for people with intellectual disabilities (e.g., Benson,
in people with disabilities, and hence was selected 1992; Taylor et al., 2002; Rossiter, et al., 1998), the
for use in the present study. extent to which clients with limitations in cognition
Clients were generally able to respond to the NAS can benefit from such an approach is not clear.
and ORS assessments adequately. For the few items Taylor et al. (2002) and others (Rose, 1996; Rose
that clients were uncertain of (e.g., when items et al., 2000; Whitaker, 2001) suggest that the
tapped domains of life they had not experienced), cognitive components of anger interventions may
these items were excluded from the scoring and a have limited efficacy in clients with intellectual
pro-rated total score was calculated. The NAS and disabilities, while non-cognitive components (e.g.,
ORS assessments were also administered post- relaxation) may have greater benefit. Nevertheless,
intervention, and at a 4-month follow-up assess- given the central role of cognition as a mediator of
ment. Of note, blind assessment at each of these anger, a cognitive restructuring component could
time points could not be achieved. In an attempt to not have been ignored. Similar to Bensons (1992)
attenuate this issue, client assessments were con- program, training in self-instruction is included, with
ducted by a psychologist who was not a facilitator for the aim being to increase the use of calm thoughts
the group the client attended, and by assessors who and reduce angry thoughts. The behavioural
did not have an ongoing professional relationship components of anger are addressed through
with or detailed knowledge of the client. problem-solving and assertiveness skills training. A
Finally, clients were administered the Peabody standard four-step problem-solving model was used,
Picture Vocabulary Test (PPVT-III: Dunn & that involved (a) defining the problem, (b) looking
Dunn, 1997) and the Ravens Coloured Progressive for possible solutions, (c) implementing the solution
Matrices (CPM: Raven, Raven, & Court, 1998) as a most likely to prove effective, and (d) evaluating the
measure of receptive vocabulary and nonverbal success of that solution (King et al., 1999; Rose et al.,
reasoning abilities respectively. Both the PPVT-III 2000). A standard model for teaching assertiveness
and CPM have particular utility as assessment training was used, that included (a) identifying
tools for individuals with complex communi- personal rights and responsibilities, (b) describing
cation needs because they do not require a verbal nonassertive behaviour and its consequences, and
response. (c) exploring the positive consequences of behaving
assertively (Holbrook Freeman & Freeman Adams,
1999).
The intervention
A prominent feature of the package is an emphasis
The intervention delivered was The Anger on pictographic symbols, functioning as a visual
Management Training Package (Gulbenkoglu & learning aid for clients with cognitive limitations, as
Hagiliassis, 2002), a new anger management pack- well as an augmentative communication medium for
age designed for individuals with a range of levels of clients with complex communication needs. The
intellectual disability and/or complex communica- importance of pictographs as an adjunct to learning
tion needs. The program is also developed to reflect is highlighted by Turk and Francis (1990), who
themes and content relevant to the lives of people found that information presented to individuals with
with physical disabilities, and incorporates adapted intellectual disabilities in the form of instruction
activities and techniques (e.g., modified relaxation) without any accompanying visual aids was rapidly
for this group. forgotten. Similarly, active learning techniques, role-
The theoretical framework adopted in the package play and repetition were emphasised to facilitate
draws on Novacos (1975) cognitive-behavioural skills acquisition.
The Anger Management Project 91
The program comprises 12 weekly sessions of 2 participate in that group, and to support clients
hours duration, including a 15-minute break. Each other than their own with activities and role-plays. A
session is fully scripted and follows a standard total of 11 out of the 14 clients in the intervention
format, beginning with a review of skills learned groups attended all 12 sessions, while two clients
during the previous session, followed by an intro- attended 11 sessions, and one client attended 10.
duction and explanation of the major session topic
and then addressing the key learning aims for that Results
session. The key elements of the content of the 12
anger management group sessions are presented in PPVT-III, CPM and age data are presented in
Table 2. Table 3. Univariate analyses of variance revealed
As two intervention groups were conducted in the there were no significant differences between the
present study, slight variations in focus, pace and intervention groups (n 5 14) and comparison groups
emphasis may have occurred across the two groups, (n 5 15) on PPVT-III and CPM measures, or on
given the realities of working with different groups age. Of note, these data indicate that both the
of participants. However, this was not felt to be a intervention and comparison groups were inclusive
significant issue and was attenuated by the standar- of individuals with a range of cognitive abilities.
dised nature of the package. Sessions were facilitated Although not directly equivalent to IQ, perfor-
by two psychologists, a male and a female in the case mances on these assessments suggest the sample
of the NW intervention group, and the same female, was inclusive not only of people with mild intellec-
along with another female, in the case of the SE tual disabilities, but also those with moderate to
intervention group. Two carers attended the SE severe intellectual disabilities. PPVT-III standard
intervention group, and they were encouraged to scores ranged from 40 to 79 for the intervention
Table 3. Age, PPVT-III and CPM data for intervention and comparison groups
comparison groups over the same time periods Relationship of improvement in anger control
remained relatively stable, from 80.01 (SD 5 to other factors
22.02) at pre-intervention, to 81.13 (SD 5 18.85)
The overall improvement shown by clients in the
at post-intervention and 80.33 (SD 5 20.10)
intervention group (anger level change, calculated as
at 4-month follow-up, with none of these differ-
the difference between NAS scores at pre-interven-
ences proving significant. Collectively, these results
tion and post-intervention) correlated significantly
indicate an improvement in anger control as a
with CPM performance (r 5 2.56, p,.05), whereas
result of participation in the intervention groups.
the correlation with PPVT-III performance
Clients in the intervention group improved relative
(r 5 2.21) was non-significant. These findings sug-
to the comparison group at post-intervention, and
gest an association between improvements in anger
relative to their own pre-intervention scores, with and level of nonverbal reasoning abilities, but not
these improvements maintained at 4-month follow- with level of receptive vocabulary. A linear regression
up. analysis (see Table 4) was undertaken to examine the
contribution of the variables of age, gender, primary
Outcome Rating Scale (ORS) results mode of communication, CPM performance and
PPVT-III performance. This analysis reveals the
The ORS data are presented in Fig. 2. A repeated only variable to account for significant variance in
measures ANOVA with ORS scores as the depen- improvements in anger was CPM performance.
dent measure reveals a non-significant main effect Conversely, the variables of age, gender, primary
for both treatment condition and time of assessment, mode of communication and PPVT-III performance
as well as a non-significant treatment condition 6 did not contribute significantly to changes in anger
time of assessment interaction effect. Although levels for the intervention group.
individuals from the intervention groups had slightly
higher ORS mean scores relative to the comparison
Discussion
groups at post-intervention and at 4-month follow-
up, these differences were non-significant. The research demonstrates that individuals who
Therefore, the data do not demonstrate reliably that participated in an intervention group showed relative
improvements in quality of life emerged as a result of improvements in self-reported levels of anger
the intervention. between pre- and post-intervention, with treatment
Table 4. Results of multiple linear regression showing the there are no specific psychometric data available on
relationship of change in anger level to other variables the ORS and its use with people with disabilities.
Further investigation of the link between anger and
Variables R2 R2 change Beta Significance
quality of life in individuals with disabilities would
Model summary .309 .309 2.556 .039 seem a useful direction for future research, as would
CPM score 2.556 .039 the accumulation of further psychometric data on
PPVT-III score 2.094 .718
tools used to measure these constructs.
Age 2.471 .109
Gender 2.432 .081
The present study has a number of methodologi-
Primary communication .391 .120 cal strengths. Foremost, the study was a randomised
mode controlled trial of an anger management intervention
in individuals with disabilities. The only other
identified randomised controlled trial is that of
effects maintained at 4-month follow-up. In con- Willner et al. (2002), who found similarly that
trast, anger levels of individuals from the comparison clients in their intervention group showed improve-
groups remained relatively stable over the same ments in anger control relative to their own pre-
period. From this, it may be concluded that the intervention scores, and to their comparison group
therapeutic approach examined in the present study post-intervention. However, the results of the pre-
was successful in reducing levels of anger in sent study potentially have greater generalisability as
individuals with a range of levels of intellectual a larger sample was used (N 5 29) compared with
disability and complex communication needs. As the Willner et al. (2002) study (N 5 14). Clearly, a
already indicated, CPM and PPVT-III scores con- focus for future research examining the efficacy of
firm that individuals representative of a range of anger management training programs for individuals
cognitive abilities, including those with moderate to with disabilities should be more controlled investiga-
severe intellectual disabilities, were sampled in the tions with larger sample numbers so that researchers
study. Additionally, there was a spread of commu- may have greater confidence in the inferences they
nication abilities sampled, ranging from clients who draw from their findings. Other strengths of the
used speech as their primary form of communica- present study, that would also appear to be valuable
tion, to clients who employed a range of nonverbal inclusions for future research, are the reporting of
communication methods, such as electronic com- robust data in order to objectively quantify the
munication devices and communication boards. effects of the intervention, the presentation of client
Given the paucity of specialised anger management characteristics in order to aid the interpretation of
programs for individuals with disabilities with a findings, and the provision of adequate reference to
range of cognitive and/or communication abilities, the content of the program in order to allow its
the finding is a welcome outcome. Effectively, replication elsewhere.
the finding extends the range of evidence-based Despite the aforementioned strengths, there are
resources available to practitioners for delivering also a number of potential limitations of the study.
interventions for individuals with anger control Even though the research was a randomised con-
issues and disabilities. trolled study, the randomised controlled nature of
In contrast to observed improvement in anger the research may have been further enhanced by the
levels, there was an absence of measured changes in inclusion of a second comparison group, one which
quality of life for the intervention group compared was involved in a placebo group activity. This would
with the comparison group. Although there was no a have provided the researchers with even greater
priori reason for expecting a relationship to emerge confidence that the improvements seen were as a
between participation in an anger intervention group result of the intervention, as opposed to being an
and improvements in quality of life, the potential artefact of participation in a group. Additionally,
finding of such a relationship would have although the study involved larger numbers of
nevertheless been a positive outcome. However, this participants than a previous randomised controlled
was not the case. One possibility is that the benefits trial, the sample size used in the present study is by
of the intervention are restricted to improvements in no means exhaustive, and a direction for future
anger control, rather than improvements in other research would be replication with a larger sample.
psychological domains, such as quality of life. Another potential limitation of the present study is
Another possibility is that the measure itself was the absence of carer reports as an external validation
not robust for this client group. Despite its selection of the improvements in self-reported levels of anger
as a tool with promising utility for the assessment of of clients in the intervention group. This was a
treatment outcomes for individuals with disabilities, conscious decision on the part of the researchers
The Anger Management Project 95
who, in line with client-centred practice, were investigating similar programs (e.g., Rose et al.,
interested in being guided by the clients own 2000; Taylor et al., 2002; Willner et al., 2002), who
perception of their anger and its impact. acknowledge that the cognitive components of such
Notwithstanding this position, qualitative data col- programs are perhaps the most difficult to employ
lected through informal discussions indicated that with individuals with intellectual disability. Further
many carers felt participants were more in control of research is required to determine which of the
their own anger on completion of the program. The physiological, behavioural and cognitive components
only exception to this was a carer for a client who of the program, or combinations thereof, are more
showed a deterioration in her anger control following responsible for producing change.
the program; this carer identified an exacerbation of Another interesting finding was a significant
challenging behaviours for that client. While it would negative correlation between CPM performance
seem useful for researchers to consider the question and change in anger scores demonstrated by
of concurrent validation of clients self-reports of participants from the intervention groups. This
anger, such as through the use of carer reports, the result suggests that individuals with more significant
decision should also be considered in the context of nonverbal reasoning deficits showed greater
client-centred practice. improvements in anger control as a result of the
Another question concerns the role of carers in the intervention, although it is important to emphasise
program. To recapitulate, in addition to the two that clients with higher level nonverbal skills also
facilitators, two carers participated in one of the benefited from the program. The reasons for this
intervention groups. It is unclear what the impact of finding are not entirely clear, but the possibility
introducing this element into the treatment process remains that some aspects of the program (e.g.,
was since no objective data were collected on this pictographic materials, pace) may have been more
factor. However, anecdotal observations suggest that suited to individuals functioning in the lower range
the inclusion of carers had a positive impact on client of nonverbal abilities. The result is in contrast to the
outcomes overall. Beyond carers providing practical findings of Willner et al. (2002), who found a non-
assistance with the delivery of activities and role- significant correlation between nonverbal IQ and
plays, they appeared to play a valuable role in terms anger outcomes for their intervention group. While it
of ensuring that the skills learnt in the context of a is difficult to ascertain the source of these inter-study
group program were generalised across other set- variations, possible contributing factors include
tings, such as home, day service or work settings. differences in participant characteristics, as well as
Along a similar line, evidence for the role of carers differences in the actual anger management pro-
in supporting skill generalisation is presented by grams evaluated by each investigation. On an
Willner et al. (2002), who noted that clients who associated matter, a somewhat perplexing result is
achieved the best outcomes were those accompanied the observation of a significant correlation between
to the group by carers. Additionally, it appeared that treatment outcomes for the intervention group and
through their involvement with the program, carers performance on the CPM, but a non-significant
became more conversant with anger management correlation between outcome and performance on
techniques, building on their capacity to work the PPVT-III. A regression analysis confirmed that
effectively with clients with anger management reasoning ability, as assessed using the CPM, was a
issues in the future. As pointed out also by Rose significant predictor of improvement, while receptive
et al. (2000), a direction for future research would be vocabulary, as assessed using the PPVT-III, did not
to examine the influence of carers in producing and contribute substantially to group outcomes. It is
maintaining change. possible that the programs emphasis on visual and
Additionally, while the results of the research active learning techniques meant that nonverbal
provide reliable evidence of the effectiveness of the reasoning skills were more likely to influence
program in reducing self-reported levels of anger in intervention outcomes compared with receptive
people with disabilities, precisely which elements of vocabulary. However, this is a tentative hypothesis
the program were most responsible for producing insofar as the cognitive factors that underpin
this change is unclear. The techniques that appeared successful outcomes in anger management programs
to be most useful were those reflecting the physio- are poorly understood. Further research is required
logical (e.g., relaxation) and behavioural (e.g., to explicate these relationships.
problem-solving) components of the program. In In conclusion, the present study provides reliable
contrast, participants appeared to have more diffi- evidence of the effectiveness of this anger manage-
culty with the cognitive elements of the program. ment intervention for individuals with a range
This opinion has also been expressed by others of levels of intellectual disability and/or complex
96 N. Hagiliassis et al.
communication needs. Beyond reinforcing the use- behaviour, BIMH Seminar Papers No. 1. Kidderminster
fulness of specialised anger management programs as British Institute of Mental Handicap.
King, N., Lancaster, N., Wynne, G., Nettleton, N., & Davis, R.
interventions for individuals with disabilities, the (1999). Cognitive-behavioural anger management training for
present study serves to highlight the importance of adults with mild intellectual disability. Scandinavian Journal of
continued research in the area, using a robust Behaviour Therapy, 28, 1922.
research methodology. Through expanding the evi- Miller, S. D., & Duncan, B. L. (2000). The Outcome Rating Scale.
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Raven, J., Raven, J. C., & Court, J. H. (1998). Manual for Ravens
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Note Rose, J. (1996). Anger management: A group treatment program
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1 Scope is an organisation providing services to over 3,500
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children and adults with physical and multiple disabilities in
Rose, J., West, C., & Clifford, D. (2000). Group interventions for
Victoria, Australia.
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