Using Anger Assessment in Children and Adolescents to Develop Treatment Plans

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Using Anger Assessment in Children and
Adolescents to Develop Treatment Plans

• Raymond DiGiuseppe, Ph.D., D.Sc., ABPPSt. John's
  UniversityandThe Albert Ellis Institute

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Anger 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.

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Anger 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.

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Anger Disorder Scale

• Behavior Domain
• lt Verbal aggression
• lt Physical aggression
• lt Passive aggression
• lt Indirect aggression
• lt Relational aggression
• lt Anger in
• Arousal Domain
• lt Duration of Axis I Problem
• lt Episode Length
• lt Physiological reactivity

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Anger Disorder Scale

• Cognitive Domain
• lt Rumination
• lt Impulsivity
• lt Suspiciousness
• lt Resentment
• Provocations
• lt Hurt / Social Rejection
• lt Scope of anger

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Anger Disorder Scale

• Motives Domain
• Coercion
• Revenge
• Tension Reduction
• Higher Order Factor Score
• Verbal Expression
• Anger In
• Vengeance

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Anger Disorder Scale

• 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

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Anger Disorder Scale Youth 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. Luttingers dissertation with a different
  method.

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Cluster Analysis

• Ward's Method
• Squared Euclidian Distances
• An 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).

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Cluster 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.

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Anger 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.

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Non 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.

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Verbal not Relational Aggression

• Here is a subtype with high coercion, revenge and
  verbal arguing.
• This is a profile most likely reserved for the
  family.

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Pure IED?

• We get a group that is impulsively aggressive
  with AVERAGE TRAIT ANGER.
• Furlong and Smith find a group like this is boys.

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High Anger and High Aggression

• Many people have both disturbed anger and
  aggression.

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What Diagnosis?

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

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What Diagnosis?

• Other Aggressive or Impulsive Diagnoses include
• IED
• Bipolar

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Anger and Impulse or Manic Disorders

• 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.

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What Diagnosis?

• 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.

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Anger 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.
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Anger 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.
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Anger and Emotional Disorders

• What about other disorders of excess affect such
  as anxiety and mood or depressive disorders?
• Do these disorders account for anger symptoms?
• NO.

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Anger 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.
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Diagnostic Criteria for Anger Regulation 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

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Diagnostic Criteria for Anger Regulation and
Expression Disorder

• 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)

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Diagnostic Criteria for Anger Regulation and
Expression Disorder

• 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

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Diagnostic Criteria for Anger Regulation and
Expression Disorder

• 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)

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Diagnostic 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.

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Diagnostic 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

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Primarily Subjective Anger Subtype

• 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

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Primarily Expressive Anger Subtype

• Self control training and impulse control
  training to not respond aggressively when
  angered.
• Assertiveness skills to replace aggression.

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Combined Angry and Aggressive Subtype

• 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

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Combined Angry and Aggressive Subtype

• 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

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Contact Ray DiGiuseppe

• Department of Psychology
• St. Johns University
• Jamaica, NY 11439
• digiuser_at_stjohns.edu