Anger Management and Intellectual Disabilities: A Systematic Review

We conducted a systematic literature review of anger management in people with intellectual disabilities (ID). We identified 2 studies that used randomized controlled trials and 6 that used pretest-posttest nonequivalent control group designs. The mean between-group effect size was 1.52 for randomized controlled trials and 0.89 for the other studies; however, no studies were well controlled. Thus, anger management is not an empirically supported treatment for individuals with ID. The need for further research in this area and methods of strengthening said research are discussed.     

Group interventions for anger in people with intellectual disabilities

This paper describes an evaluation of a group intervention for reducing inappropriately expressed anger (as aggression) in people with intellectual disabilities. Group intervention was compared to a treatment as usual group consisting of people referred to the group but who had to wait to participate. The intervention used was based on the work of Novaco (1976; 1978) and Benson (1994). However, further modifications to the group that emphasized the contextual perspective of anger, such as the participants being accompanied by a support worker and more collaborative recording procedures, were devised. A reduction in expressed anger and measured levels of depression occurred after group treatment. Reductions in expressed anger were maintained at 6 and 12 months follow up. However, scores on the depression scale tended to increase on follow up. While caution must be expressed when considering these results, this type of intervention shows promise for reducing inappropriately expressed anger in people with intellectual disabilities Suggestions are made for future research and clinical practice.     

Individual Cognitive Behavioral Intervention for Anger

There is growing evidence for the efficacy of programs to reduce inappropriate aggression in people with intellectual disabilities. These have been provided in groups and for individuals in forensic settings. People with intellectual disability and inappropriately expressed anger who were referred to a community psychology service were assigned to either individual intervention or a waiting list control. Participants were assessed both before and after treatment using an anger provocation inventory. Improvements were found in the scores obtained on the Anger Inventory for those receiving individual treatment when compared with the control group using a 2-by-2 split plot Analysis of Variance (ANOVA). These results suggest that individual cognitive behavioral intervention may be an effective treatment option in community settings.     

Forensic aspects in people with intellectual disabilities

PURPOSE OF REVIEW: The past few years have seen a growth in research of forensic issues relating to people with intellectual disabilities. This review examines a broad spectrum covering 2005 and 2006, for which articles are already available. Given the diversity of publications, reference will also be made to some of the main articles of 2004 to provide a context. RECENT FINDINGS: We are now at the stage where people are questioning the existing forensic psychiatry evidence base for people with intellectual disabilities. This review examines the assessment and treatment of three different groups, that is, fire setters, sexual offenders and those with problems of anger and aggression along with service outcome research, the criminal justice system, and a round up of other related research. SUMMARY: The growth of research in this area has aided the development of assessment and treatment instruments and treatment models for people with intellectual disabilities. This has helped to highlight the specialist and complex nature of this group. The review also looks at services from the point of delivery and the difficulty in research methodology and quantifying outcomes that take into account a changing society and current health inequalities.     

Assessment of anger coping skills in individuals with intellectual disabilities

Recent controlled studies have supported the effectiveness of anger management training for people with intellectual disabilities (IDs). This report describes an evaluation instrument designed to assess their usage of specific anger coping skills. The Profile of Anger Coping Skills (PACS) is designed for completion by a staff member or carer. Three situations are first elicited in which a client frequently displays anger. The respondent then rates each situation for the extent to which the client deploys each of eight behavioural and cognitive coping skills. In a preliminary reliability study, 20 users of a day service for people with IDs were rated independently by two staff members, with one of them completing the assessment on two separate occasions: the PACS showed good test–retest reliability and lower, but still acceptable, interrater reliability. The PACS was subsequently used, in a different day service, as part of the assessment pack administered before and after a 12-week anger management group, with a parallel assessment of an untreated control group. The treated group showed substantial decreases in measures of anger, which were maintained at 6-month follow-up. Increases in PACS-rated anger coping skills were also seen in all participants in the anger management group, but not in the control group. There were differences in the extent to which different coping skills were acquired by the treated group, and there were also individual differences in the profile of specific skills acquired. It is concluded that the PACS is a reliable instrument for assessing anger coping skills, particularly when used repeatedly with the same informant. It provides information that is useful for both individual care planning and the design of future anger management programmes.     

Treating Individuals With Intellectual Disabilities and Challenging Behaviors With Adapted Dialectical Behavior Therapy

Approximately one third of adults with intellectual and developmental disabilities have emotion dysregulation and challenging behaviors (CBs). Although research has not yet confirmed that existing treatments adequately reduce CBs in this population, dialectical behavior therapy (DBT) holds promise, as it has been shown to effectively reduce CBs in other emotionally dysregulated populations. This longitudinal single-group pilot study examined whether individuals with impaired intellectual functioning would show reductions in CBs while receiving standard DBT individual therapy used in conjunction with the Skills System (DBT-SS), a DBT emotion regulation skills curriculum adapted for individuals with cognitive impairment. Forty adults with developmental disabilities (most of whom also had intellectual disabilities) and CBs, including histories of aggression, self-injury, sexual offending, or other CBs, participated in this study. Changes in their behaviors were monitored over 4 years while in DBT-SS. Large reductions in CBs were observed during the 4 years. These findings suggest that modified DBT holds promise for effectively treating individuals with intellectual and developmental disabilities.     

Relationships among moral reasoning, empathy, and distorted cognitions in men with intellectual disabilities and a history of criminal offending

Eighty men, spread equally across 4 groups, were recruited, including men with and without intellectual disabilities. The men were either criminal offenders or nonoffenders. Participants completed measures of moral reasoning, empathy, and distorted cognitions. The results indicated that the moral reasoning abilities of offenders with intellectual disabilities were developmentally delayed but were still more mature than those of nonoffenders with intellectual disabilities. Offenders without intellectual disabilities had less mature moral reasoning abilities than nonoffenders without intellectual disabilities. The differences may be partially accounted for by intellectual ability. The results also indicated that the relationship between empathy and distorted cognitions was mediated by moral reasoning. The findings have implications for the use of psychological interventions with offenders with intellectual disabilities.     

Changes in Personality Disorder Traits Following 2 Years of Treatment in a Secure Therapeutic Community Milieu

Therapeutic community treatment models have not previously been applied to forensic patients with mild intellectual disabilities (IDs) with a comorbid diagnosis of personality disorder. Thirteen patients with mild IDs were allocated to a unit within a high secure psychiatric service operating a model of treatment based on the principles and practices of therapeutic communities. After 2 years, 9 patients remained in treatment. Self-rated personality disorder traits, maladaptive schema relating to personality disorder, and clinician-rated psychopathy were measured at start of treatment and after 2 years. Seclusion hours were measured for 6 months before treatment and during the 2 years of treatment. There were significant reductions in antisocial, schizoid and paranoid traits, and in schemas relating to entitlement, defectiveness, emotional inhibition, and vulnerability. There were no changes in ratings of psychopathic traits. Mean seclusion hours had reduced by over 90% in the latter 6 months of treatment compared with the 6 months before treatment. The results provide encouraging support for a therapeutic community approach for some individuals with mild IDs and personality disorder diagnoses and are discussed in the light of the severe pathology of the patients undergoing treatment. Therapeutic community approaches are nevertheless consistent with the move toward greater patient involvement in services and treatment.     

Peer with intellectual disabilities as a mindfulness-based anger and aggression management therapist

A young man with intellectual disabilities (ID) and mental illness, who had previously been taught to successfully manage his aggressive behavior by using Meditation on the Soles of the Feet, reported that he shared his mindfulness practice with his peers with ID. When requested by his peers, and without any training as a therapist, he began to teach this procedure to his peers for controlling their anger and aggressive behavior. We tracked the anger and aggressive behavior of three of the individuals he taught and the fidelity of his teaching of the procedure. According to self and staff reports, anger and aggressive behavior of the three individuals decreased to very low levels within five months of initiating training and remained at very low levels for the two years during which informal data were collected. The fidelity of his teaching the procedure was high, if one allows for his idiosyncratic teaching methods. These findings suggest that individuals with mild ID, who have mastered an effective mindfulness-based strategy to control their aggressive behavior, may be able to teach their peers the same strategy to successfully control their anger and aggressive behavior to a level that is acceptable for community living.     

Cognitive-behavioural treatment for men with intellectual disabilities and sexually abusive behaviour: a pilot study

Background Cognitive‐behaviour therapy (CBT) seems to be becoming the treatment of choice for non‐disabled sex offenders. Nevertheless, there have been relatively few evaluations of such treatment for men with intellectual disabilities (ID) and sexually abusive behaviour. Method A pilot study providing CBT for two groups of men with ID is described. Measures of change in sexual knowledge, victim empathy and cognitive distortions were collected, together with a log of further sexually abusive behaviour. Results Fifteen men were offered treatment but some dropped out and some declined to take part in the research. The results for the eight men who consented to the research and completed treatment showed significant positive changes in sexual knowledge and victim empathy (two men completed both groups, making 10 sets of data in all). Cognitive distortions showed significant change on only one of the two measures. Some men showed further sexually abusive behaviour either during or after the treatment group (all had been previously diagnosed as on the autistic spectrum). Conclusion There is a need for a larger multi‐site trial of treatment with a broad set of measures and the ability to analyse who benefits from such treatments and who does not.     

Antisocial and delinquent behaviors in youths with mild or borderline disabilities

Six types of antisocial and delinquent behaviors (e.g., property destruction and authority avoidance) were assessed in 526 youths (11 to 24 years of age) with mild to borderline intellectual disabilities and 1,030 11- to 18-year-olds without intellectual disabilities. Overall, 10% to 20% of youths with intellectual disabilities exhibited some type of antisocial and delinquent behavior, which were quite persistent over a 5-year period. Youths who exhibited one type of antisocial and delinquent behavior were likely to also exhibit other types of such behaviors. Being male, younger, and having behavioral problems particularly predicted these behaviors across a 5-year period. Overall, boys but not girls with intellectual disabilities exhibited antisocial and delinquent behaviors more often than peers without intellectual disabilities. Clinical implications and implications for future research are discussed.     

Peeking into the black box: Mechanisms of action for anger management treatment

We investigated potential mechanisms of action for anger symptom reductions, specifically, the roles of anger regulation skills and therapeutic alliance on changes in anger symptoms, following group anger management treatment (AMT) among combat veterans with posttraumatic stress disorder (PTSD). Data were drawn from a published randomized controlled trial of AMT conducted with a racially diverse group of 109 veterans with PTSD and anger symptoms residing in Hawaii. Results of latent growth curve models indicated that gains in calming skills predicted significantly larger reductions in anger symptoms at post-treatment, while the development of cognitive coping and behavioral control skills did not predict greater symptom reductions. Therapeutic alliance had indirect effects on all outcomes mostly via arousal calming skills. Results suggest that generalized symptom reduction may be mediated by development of skills in calming physiological arousal. In addition, arousal reduction skills appeared to enhance one's ability to employ other anger regulation skills.     

Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues

Background Clinicians working with clients who have mild intellectual disabilities (IDs) have shown growing enthusiasm for using a cognitive behavioural approach, amid increasing evidence of good treatment outcomes for this client group. However, very little is known about the views and experiences of clients with IDs who have undergone cognitive behavioural therapy. This study aims to explore the perspective of these clients. Methods Fifteen participants with borderline to mild IDs and problems of anxiety, depression and anger were interviewed regarding their experience of cognitive behavioural therapy (CBT). Two semi‐structured interviews were carried out in the first phase of therapy between session four and session nine. An interpretive phenomenological approach was taken to seek out themes from participants' own personal accounts. Results Participants valued the opportunity to talk about problems with their therapist and benefitted from therapeutic relationships characterised by warmth, empathy and validation. Participants identified areas of positive change; however, many thought that this may be short lived or not maintained beyond discharge. Conclusions The supportive aspects of therapeutic relationships were particularly important to participants undergoing CBT. The clinical implications are considered.     

Sexual abuse perpetrated by men with intellectual disabilities: a comparative study

This paper compares cases of sexual abuse of adults with intellectual disabilities, reported across the South East of England, which were perpetrated by men with intellectual disabilities, with those committed by other male perpetrators. The comparison provides some support for the findings of other studies, which have suggested that men with intellectual disabilities offend against more male victims than non-disabled sex offenders and that their offences are somewhat less serious, but otherwise indicates common patterns of abusive behaviour across this divide but differential service responses and support for victims. So called ‘peer abuse’ is a widespread problem which service agencies have failed to address: repeated offences are frequent and lack of appropriate intervention is the norm.     

Midlife and aging parents of adults with intellectual and developmental disabilities: impacts of lifelong parenting

Using population data, this study included parents of individuals with intellectual and developmental disabilities (n = 220) and parents of individuals without disabilities (n = 1,042). Parents of individuals with intellectual and developmental disabilities were further divided into those who co-resided with their adult child and those whose adult child lived elsewhere, and the 3 groups were compared regarding parental patterns of attainment, social participation, psychological functioning, and health in midlife and early old age. In midlife, parents of individuals with intellectual and developmental disabilities were similar in general to comparison parents. However, by early old age, these parents had poorer health and mental health. Co-residence between the adult with intellectual and developmental disabilities and the parent was prevalent during midlife (51.4%) and in the early years of old age (38.6%), and there were different patterns of parental outcomes, depending on the residential status of the adult with intellectual and developmental disabilities.     

Spinal and limb abnormalities in adolescents with intellectual disabilities

There are not many studies pertaining to the spinal or limb abnormalities in people with intellectual disabilities, without a clear profile of these deformities of them, efforts to understand its characters and improve their quality of life will be impossible. Therefore, this paper aims to describe the prevalence and related factors of spinal and limb abnormalities in adolescents with intellectual disabilities. The participants who participated in health examinations as they enrolled into special schools at the first year, a total of 822 aged 15–18 years adolescents with ID were recruited to this study. The results showed that there were 14.5% and 8.5% cases had spinal and limb abnormalities based on the physician's observation and X-ray test. Factors of BMI level and limb abnormalities were significantly predicted the spinal abnormality occurrence in those adolescents with ID. Gender, disability level and have a spinal abnormality were variables that can statistically correlate to limb abnormality condition. The study highlights that in order to ensure people with intellectual disabilities receive an appropriate quality of care, it is important to have a precise understanding of the ways in which the needs of them who have spinal or limb deformities differ from the sole intellectual disability and the general population as a whole.     

Cell phone use by adults with intellectual disabilities

Although cell phone use has grown dramatically, there is a gap in cell phone access between people with disabilities and the general public. The importance of cell phone use among people with intellectual disabilities and studies about use of cell phones by adults with intellectual disabilities was described. Our goal was to determine the extent and scope of cell phone use by 83 adults with intellectual disabilities, reasons for nonuse, and factors affecting use. Results suggest a gap in the use of cell phone technology between people with intellectual disabilities and the general population. When used, they are employed primarily for emergencies, storing telephone numbers, and day-to-day communication. Chief reasons for nonuse include cost, perception of not needing one, and lack of accessibility.