Assessment of anger and aggression in male offenders with developmental disabilities

The use of proxy measurement of internal states in people with intellectual disability: A scoping review

BACKGROUND

The measurement of internal states of people with an intellectual disability is challenging. Given these difficulties, proxy respondents are sometimes used. However, the literature provides some caution about the validity of the use of proxy respondents.

AIMS

This review aims to identify the available evidence regarding the use of proxy respondents in the measurement of internal states of people with intellectual disabilities.

METHOD

The Arksey and O'Malley scoping review framework was used for this review, refined with the Joanna Briggs Institute Methodology.

RESULTS

Results indicate there are some differences in the findings reported with respect to the efficacy of the use of proxy respondents. These may be due to a number of inconsistencies and weaknesses in examinations of their utility.

CONCLUSIONS

If proxy-reports are to be useful in understanding the internal states of people with intellectual disability, researchers need to address the shortcomings revealed by this review.

Cognitive behavioural anger treatment for adults with intellectual disabilities: effects of therapist experience on outcome

BACKGROUND

Anger has been shown to be associated with aggression and violence in adults with intellectual disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger and violent behaviour in these patient populations. However, it has been suggested that the effectiveness of these types of interventions is influenced by the experience and training of the therapists.

METHOD

In this service evaluation study, the pre- and post-treatment and 12-month follow-up assessment scores of 88 detained in-patient adults with intellectual disabilities and forensic histories who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was associated with treatment being delivered by qualified versus unqualified therapists.

RESULTS

Overall significant reductions in self-reported measures of anger disposition and anger reactivity were found with no significant time × therapist experience interaction effects. However, the patients treated by qualified therapists improved significantly on measures of anger control compared with those allocated to unqualified therapists.

CONCLUSIONS

Male and female detained patients with intellectual disabilities and forensic histories can benefit from an individual cognitive behavioural anger treatment intervention delivered by qualified and unqualified therapists, but therapist experience may be important in supporting patients to develop more complex anger control coping skills.

Anger rumination and imagined violence as related to violent behavior before and after psychiatric hospitalization

OBJECTIVE

Anger rumination and imagined violence, in the context of anger/aggression proclivity, are examined for their direct and conjoint associations with violent behavior by psychiatric patients.

METHOD

A secondary analysis of data from the MacArthur Violence Risk Study was conducted with 1136 acute civil commitment patients, assessed during hospitalization and after hospital discharge. Anger/aggression proclivity was assessed with the Brief Psychiatric Rating Scale hostility subscale, anger rumination was indexed using items from the Novaco Anger Scale, and imagined violence was measured with Grisso's Schedule of Imagined Violence. Violence, prehospitalization and posthospitalization, was indexed by the MacArthur project measure.

RESULTS

Correlational analyses, mediation analyses, and moderated mediation analyses were conducted. Anger rumination significantly predicted pre- and posthospitalization violence, when controlling for age, sex, race, childhood physical abuse, and anger/aggression proclivity; and it partially mediated the relation between anger/aggression proclivity and violence. Imagined violence and anger rumination were highly inter-related. When imagined violence was added to the regression model, it was a significant predictor of prehospitalization violence; however, it did not moderate the association of anger rumination with pre- or posthospitalization violence.

CONCLUSION

Anger rumination may be a mechanism through which anger activates violent behavior, which has important implications for psychotherapeutic intervention targeting. Future research should investigate the association between anger rumination and imagined violence, with attention given to revenge planning as a link.

Exploring the usefulness of medical clowns in elevating satisfaction and reducing aggressive tendencies in pediatric and adult hospital wards

BACKGROUND

Most existing research on medical clowns in health care services has investigated their usefulness mainly among child health consumers. In this research we examined multiple viewpoints of medical staff, clowns, and health consumers aiming to identify the optimal audience (adult or child health consumers) for which medical clowns are most useful. We focused on exploring their usefulness in enhancing health consumers' satisfaction and, in turn, reducing their aggressive tendencies.

METHODS

We conducted three studies that examined the placement fit of medical clowns from different points of view: medical staff (Study 1, n = 88), medical clowns (Study 2, n = 20), and health consumers (Study 3, n = 397). The main analyses in Studies 1 and 2 included frequencies and t-tests comparing perceived adult and child satisfaction with clowns' performance. Study 3 used moderated-mediation PROCESS bootstrapping regression analysis to test the indirect effect of negative affectivity on aggressive tendencies via satisfaction. Exposure to the medical clown moderated this relationship differently for different ages.

RESULTS

Studies 1 and 2 show that the majority of medical clowns and medical staff report that the current placement of the medical clowns is in pediatric wards; about half (44% of medical staff, 54% of medical clowns) thought that this placement policy should change. In Study 3, data from health consumers in seven different hospital wards showed that clowns are useful in mitigating the effect of negative affectivity on satisfaction, thereby reducing aggressive tendencies among health consumers under the age of 21.6 years. Surprisingly, medical clowns had the opposite effect on most adults: for health consumers who were exposed to the medical clown and were above the age of 21.6 negative affectivity was related to decreased satisfaction, and an increase in aggressive tendencies was observed.

DISCUSSION

Medical clowns are most useful in elevating satisfaction and reducing aggressive tendencies of children. Older adults, on the other hand, exhibit lower satisfaction and higher aggressive tendencies following exposure to the performance of medical clowns.

CONCLUSION

Medical clowns should be placed primarily in children's wards.

Behavioural, psychiatric and psychosocial factors associated with aggressive behaviour in adults with intellectual disabilities: A systematic review and narrative analysis

Background

Aggressive behaviour is prevalent in people with intellectual disabilities. To understand the aetiology, it is important to recognize factors associated with the behaviour.

Method

A systematic review was conducted and included studies published between January 2002 and April 2017 on the association of behavioural, psychiatric and psychosocial factors with aggressive behaviour in adults with intellectual disabilities.

Results

Thirty‐eight studies were included that presented associations with 11 behavioural, psychiatric and psychosocial factors. Conflicting evidence was found on the association of these factors with aggressive behaviour.

Conclusions

The aetiology of aggressive behaviour is specific for a certain person in a certain context and may be multifactorial. Additional research is required to identify contributing factors, to understand causal relationships and to increase knowledge on possible interaction effects of different factors.

Anger and depression among incarcerated male youth: Predictors of violent and nonviolent offending during adjustment to incarceration

OBJECTIVE

Anger and depression are associated with a number of psychosocial problems, and their comorbidity may exacerbate maladjustment among incarcerated youth. The present study aims to identify whether anger and its different facets (cognitive, arousal, and behavioral), either independently or when conjoined with depressed mood, affects violent and nonviolent institutional infractions.

METHOD

Male adolescents (14-17 years of age) were recruited within 48 hr of arrival at a juvenile detention facility and were administered psychometric measures of anger (Novaco Anger Scale) and depression (Center for Epidemiological Studies-Depression scale) at baseline, 1 month, and 2 months. Offending within the facility was assessed via self-report and institutional records.

RESULTS

Controlling for prior offending and other background factors, individuals having high anger scores were more likely to offend over the 2-month period, compared to those with lower levels of anger. Novaco Anger Scale scores, especially the Behavioral facet, predicted both official- and self-reported (violent and nonviolent) institutional offending. There was evidence for the interaction of depression and anger at baseline predicting self-reported offending at 1 month only.

CONCLUSIONS

Given that juveniles' self-report of emotional distress, particularly anger, is predictive of their violent and nonviolent infractions, focused intervention programs could reduce behavior problems during incarceration that add to juveniles' maladjustment and continued exposure to adversities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prepartum and Postpartum Mothers' and Fathers' Unwanted, Intrusive Thoughts in Response to Infant Crying

BACKGROUND

Unwanted intrusive thoughts of intentionally harming one's infant (intrusive harm thoughts) are common distressing experiences among postpartum mothers and fathers.

AIM

To understand infant crying as a stimulus for intrusive harm thoughts and associated emotional responses in prepartum and postpartum mothers and fathers in response to infant cry.

METHOD

Following completion of self-report measures of negative mood and anger, prepartum (n = 48) and postpartum (n = 44) samples of mother and father pairs completed 10 minutes of listening to audio-recorded infant crying. Post-test questionnaires assessed harm thoughts, negative emotions, urges to comfort and flee, and thoughts of shaking as a soothing or coping strategy.

RESULTS

One quarter of prepartum and 44% of postpartum parents reported intrusive infant-related harm thoughts following crying. Mothers and fathers did not differ in the likelihood of reporting harm thoughts, nor in the number of thoughts reported. Women reported more internalizing emotions compared with men. Hostile emotions were stronger among postpartum parents, and parents reporting harm thoughts. All parents reported strong urges to comfort the infant. Urges to flee were stronger among parents who reported harm thoughts. The likelihood of using infant shaking as a soothing or coping strategy was minimally endorsed, albeit more strongly by fathers and parents who also reported harm thoughts.

CONCLUSIONS

In response to crying, harm thoughts are common and are associated with hostile emotions, urges to flee, and increased thoughts of using infant shaking. Reassuringly, the number of participants considering infant shaking as a strategy for soothing or for coping with a crying infant was low.

Treatment of trauma related anger in operation enduring freedom, operation Iraqi freedom, and operation New Dawn veterans: Rationale and study protocol

Background

Problems with anger and aggression are highly prevalent in Veterans of multiple war eras, including the most recent conflicts in Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF). The consequences of these problems, such as increased rates of divorce, domestic violence, occupational instability, arrests and incarceration, are often devastating. Despite the seriousness of these problems, relatively little is known about effective treatments for anger in Veterans.

Method and design

This paper describes the rationale and study protocol of a randomized controlled trial comparing an adapted cognitive behavioral intervention (CBI) with an active control condition (supportive intervention, SI) for the treatment of anger problems in OEF/OIF Veterans. The sample includes 92 OEF/OIF Veterans, randomized to CBI or SI. Both treatments include 12 weekly, 75-min individual sessions. Participants are assessed at baseline, after sessions 4 and 8, at post-treatment, and at 3 and 6 months post-treatment. Primary outcomes are reduction in anger and aggression; secondary outcomes are improved functioning and quality of life. We hypothesize that CBI will be associated with significantly more improvement than SI on primary and secondary measures.

Discussion

Findings from this study will help to address the gap in evidence for effective treatments for anger in Veterans. The use of an active control condition will provide a stringent test of the effects of CBI beyond that of common factors of psychotherapy such as therapeutic relationship, mobilization of hope, and support. Findings have the potential to improve treatment outcomes for Veterans struggling with post-deployment anger problems.

Violent incidents in a secure service for individuals with learning disabilities: Incident types, circumstances and staff responses

BACKGROUND

The issue of violence in secure services has long been recognized both in the UK and worldwide. However, there is currently scarce literature available about violence within learning disability (LD) secure settings.

METHODS

Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a 1-year period.

RESULTS

Physical assaults were the most frequent type of incident, and the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalized linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff.

CONCLUSIONS

These findings can inform staff training on violence prevention and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

The Metacognitive Anger Processing (MAP) Scale – Validation in a Mixed Clinical and a Forensic In-Patient Sample

Background: The metacognitive approach by Wells and colleagues has gained empirical support with a broad range of symptoms. The Metacognitive Anger Processing (MAP) scale was developed to provide a metacognitive measure on anger (Moeller, 2016). In the preliminary validation, three components were identified (positive beliefs, negative beliefs and rumination) to be positively correlated with the anger. Aims: To validate the MAP in a sample of mixed clinical patients (n = 88) and a sample of male forensic patients (n = 54). Method: The MAP was administered together with measures of metacognition, anger, rumination, anxiety and depressive symptoms. Results: The MAP showed acceptable scalability and excellent reliability. Convergent validity was evidenced using the general metacognitive measure (MCQ-30), and concurrent validity was supported using two different anger measures (STAXI-2 and NAS). Conclusions: The MAP has promising potential to assess anger regulation problems by providing a framework on angry rumination as well as the belief structures that proposedly drive the selection of this maladaptive processing strategy as suggested in the metacognitive model. These findings may have implications for clinical interventions. For example, conducting functional analyses on anger rumination could increase the understanding of dysregulated anger processing and lead to new interventions focused on shifting thinking style.

Exploring Differences in Criminogenic Risk Factors and Criminal Behavior Between Young Adult Violent Offenders With and Without Mild to Borderline Intellectual Disability

The relation between mild to borderline intellectual disability (MBID) and violent offense behavior was studied among a group of former juvenile delinquents currently in a diversion program for persistent young adult violent offenders from Amsterdam ( N = 146). Offenders were considered MBID if they had received juvenile probation from the local youth care agency specialized in intellectual disability (21%). A file study was used to estimate prevalence rates of criminogenic risk factors. Police data were used to depict recent criminal behavior. Nearly all offenders grew up in large and unstable multi-problem households and had psychosocial problems. More MBID offenders displayed externalizing behavior before the age of 12, were susceptible to peer pressure, and had low social-relational skills. MBID offenders committed more violent property crimes than offenders without MBID. Youth care interventions for MBID offenders should focus on the acquisition of social-relational skills and on the pedagogical skills of parents.

Development and psychometric properties of the Psychological Therapies Outcome Scale - Intellectual Disabilities (PTOS-ID)

BACKGROUND

There are few valid and reliable psychological therapy outcome measures available for use with people with intellectual disabilities (ID). The current study involved the development of a new scale; the Psychological Therapies Outcome Scale - Intellectual Disabilities (PTOS-ID), and the examination of its validity and internal consistency.

METHOD

The PTOS-ID was administered to 175 people who have ID accessing specialist ID services. The construct validity of the scale was investigated through exploratory factor analysis, concurrent validity through comparison with the Brief Symptom Inventory and internal reliability through internal consistency analysis.

RESULTS

Three factors emerged from the principal components analysis with high levels of internal consistency: (1) anger and mood (α = 0.82); (2) positive well-being (α = 0.81); and (3) anxiety (α = 0.76). Factors (1) and (2) were combined to measure psychological distress (α = 0.85), which correlated strongly with the Global Severity Index of the Brief Symptom Inventory (r = 0.85).

CONCLUSIONS

This preliminary study suggests that the PTOS-ID is a psychometrically robust measure of psychological distress and psychological well-being that can be used with people with ID. Further research is required to assess its reliability and ability to detect change.

A systematic review of the evidence regarding cognitive therapy skills that assist cognitive behavioural therapy in adults who have an intellectual disability

BACKGROUND

Cognitive behavioural therapy (CBT) is being increasingly adapted for use with people who have an intellectual disability. However, it remains unclear whether inherent cognitive deficits that are present in adults who have an intellectual disability preclude the use of cognitive-based therapies. This review aims to systematically examine "cognitive therapy skills" in adults who have an intellectual disability that assist engagement in CBT.

METHOD

Two authors independently reviewed titles and abstracts of articles located through electronic database searching.

RESULTS

Outcomes of the 18 studies selected for full-text review are mixed and limited by a moderately high risk of bias.

CONCLUSIONS

The authors suggest eleven findings from research areas of emotion recognition, cognitive mediation, discriminating between thoughts, feelings and behaviours, linking events and emotions that have implications for the design of CBT programmes and future research for this population.

Reasoning and Rehabilitation cognitive skills programme for mentally disordered offenders: Predictors of outcome

AIM

To investigate factors predicting treatment completion and treatment outcome of the Reasoning and Rehabilitation Mental Health Programme (R&R2MHP) cognitive skills programme for mentally disordered offenders.

METHODS

Secondary analysis of data previously obtained from 97 male patients who were sectioned and detained under the United Kingdom Mental Health Act in low, medium and high security hospitals and who had completed R&R2MHP. Predictors of treatment completion included background variables and five outcome measures: Four self-reported measures of violent attitudes, social problem-solving skills, reactive anger and locus of control and an objective measure of behaviour on the ward that was completed by staff. Completion of the 16 session programme, which was delivered on a weekly basis, was classified as ≥ 12 sessions.

RESULTS

It was found that the R&R2MHP is appropriate for delivery to participants of different ages, ethnic background, and at different levels of security without the completion rate or treatment effectiveness being compromised. Participants taking oral typical psychotropic medication were over seven times more likely to complete the programme than other participants. Behavioural disturbance on the ward prior to commencing the programme predicted non-completion (medium effect size). As far as treatment completion was concerned, none of the background factors predicted treatment effectiveness (age, ethnic background, level of security, number of previous convictions and number of previous hospital admissions). The best predictor of treatment effectiveness was attitude towards violence suggesting that this should be the primary outcome measure in future research evaluating outcomes of the R&R2MHP cognitive skills program.

CONCLUSION

The findings suggest that a stable mental state is a key factor that predicts treatment completion.

Can a mindfulness-informed intervention reduce aggressive behaviour in people with intellectual disabilities? Protocol for a feasibility study

BACKGROUND

Approximately 10-20 % of adults with intellectual disabilities engage in challenging behaviours such as aggression, destructiveness, and self-injury, which are often accompanied by feelings of anger. The inability to manage anger can reduce quality of life. For example, aggression is a strong predictor of out-of-area placements and is a risk variable for abuse. Recent research suggests that mindfulness-based therapies (specifically, Singh's Soles of the Feet meditation) can help people with intellectual disabilities manage angry emotions, with resultant reductions in challenging behaviour. However, previous research has been single-case design studies, and no group studies have been published with people with intellectual disabilities and aggressive behaviour.

METHODS/DESIGN

For this feasibility study, a UK protocol will be developed for use by health professionals within National Health Service (NHS) Intellectual Disability (ID) teams, based upon Singh's Soles of the Feet manual. Twenty adults with intellectual disabilities and identified problems with anger control will be recruited and six sessions will be delivered by a trained ID clinician. The study will monitor participant's aggressive behaviour, health-related quality of life, anxiety, depression, and use of support services (medication, hospital appointments etc.). These will be measured at three time points: (1) Baseline (within 2 weeks prior to the first session of the intervention), (2) 2 months post-baseline, and (3) 6 months post-baseline. Qualitative interviews will be conducted with participants, their carers, and the therapists who delivered the intervention. In order to help design an economic evaluation alongside a future full trial, we will cost the intervention and test the acceptability and validity of health economics measures to record resource use and health-related quality of life outcomes.

DISCUSSION

The data from this study will inform the feasibility of the project protocol and intervention, which will help develop future research and to determine whether a larger, randomised controlled trial with concurrent economic evaluation is feasible.

TRIAL REGISTRATION

UKCERN: 16743.

The Structured Assessment of Violence Risk in Adults with Intellectual Disability: A Systematic Review

BACKGROUND

While structured professional judgement approaches to assessing and managing the risk of violence have been extensively examined in mental health/forensic settings, the application of the findings to people with an intellectual disability is less extensively researched and reviewed. This review aimed to assess whether risk assessment tools have adequate predictive validity for violence in adults with an intellectual disability.

METHODS

Standard systematic review methodology was used to identify and synthesize appropriate studies.

RESULTS

A total of 14 studies were identified as meeting the inclusion criteria. These studies assessed the predictive validity of 18 different risk assessment tools, mainly in forensic settings. All studies concluded that the tools assessed were successful in predicting violence. Studies were generally of a high quality.

CONCLUSIONS

There is good quality evidence that risk assessment tools are valid for people with intellectual disability who offend but further research is required to validate tools for use with people with intellectual disability who offend.

The Use of the State-Trait Anger Expression Inventory-II With Forensic Populations: A Psychometric Critique

The State-Trait Anger Expression Inventory-II (STAXI-II) is a psychometric assessment that measures the experience, expression, and control of anger in research and clinical settings. Although the STAXI-II is extensively used and its psychometric properties supported, no psychometric critique has yet specifically assessed its utility with forensic populations. The aim of this critique was to explore the validity and reliability of the STAXI-II when used with forensic samples. It was found that the psychometric properties of the STAXI-II, when used with forensic populations, are satisfactory. However, gaps in research and issues that need to be addressed in practice have been highlighted. Although STAXI-II provides a comprehensive measure of anger, it does not capture all aspects of the construct. In addition, the tool does not contain an inherent validity scale, indicating the need to control for social desirability responding when administering the STAXI-II. Practical implications, limitations, and future research will be discussed.

Validation of the Novaco Anger Scale–Provocation Inventory (Danish) With Nonclinical, Clinical, and Offender Samples

Anger has high prevalence in clinical and forensic settings, and it is associated with aggressive behavior and ward atmosphere on psychiatric units. Dysregulated anger is a clinical problem in Danish mental health care systems, but no anger assessment instruments have been validated in Danish. Because the Novaco Anger Scale and Provocation Inventory (NAS-PI) has been extensively validated with different clinical populations and lends itself to clinical case formulation, it was selected for translation and evaluation in the present multistudy project. Psychometric properties of the NAS-PI were investigated with samples of 477 nonclinical, 250 clinical, 167 male prisoner, and 64 male forensic participants. Anger prevalence and its relationship with other anger measures, anxiety/depression, and aggression were examined. NAS-PI was found to have high reliability, concurrent validity, and discriminant validity, and its scores discriminated the samples. High scores in the offender group demonstrated the feasibility of obtaining self-report assessments of anger with this population. Retrospective and prospective validity of the NAS were tested with the forensic patient sample regarding physically aggressive behavior in hospital. Regression analyses showed that higher scores on NAS increase the risk of having acted aggressively in the past and of acting aggressively in the future.

Dialectical Behaviour Therapy [DBT] with People with Intellectual Disabilities: A Systematic Review and Narrative Analysis

BACKGROUND

There is mixed evidence regarding the effectiveness of psychological therapies for people with intellectual and developmental disorders. Although systematic reviews have supported the use of dialectical behaviour therapy with people with borderline personality disorder, there are no comparable reviews regarding DBT with people with intellectual and development disabilities.

METHODS

Studies were identified using a systematic approach and were selected if they reported an intervention that included a DBT skills group and then assessed using the Evaluative Method for Determining Evidence Based Practice.

RESULTS

Seven studies reported adaptations and outcomes of DBT for people with intellectual and development disabilities, four of which delivered full DBT programmes with three describing DBT skills groups. All studies were appraised with regard to methodological quality and the adaptations and results examined.

CONCLUSIONS

The findings indicate that DBT and DBT skills groups can be adapted for people with intellectual and development disabilities, but further high-quality research is needed to make conclusions about efficacy and effectiveness.

Assessment of Anger-Related Cognitions of People with Intellectual Disabilities

BACKGROUND

Interventions for anger represent the largest body of research on the adaptation of cognitive behavioural therapy (CBT) for people with intellectual disabilities. The extent to which the effectiveness of these interventions reflects the behavioural or cognitive components of CBT is uncertain. This arises in part because there are few measures of anger-related cognitions.

METHOD

The Profile of Anger-related Cognitions (PAC) is built around interpersonal scenarios that the participant identifies as personally anger-provoking, and was designed as an extension of the Profile of Anger Coping Skills (PACS). A conversational presentational style is used to approach ratings of anger experienced in those situations and of four relevant cognitive dimensions: attribution of hostile intent, unfairness, victimhood, and helplessness. The PAC, and other measures, including the PACS, was administered to (i) people with ID identified as having problems with anger control (n = 12) and (ii) university students (n = 23); its psychometric properties were investigated and content analyses were conducted of participants' verbal responses. In a third study, clinicians (n = 6) were surveyed for their impression of using the PAC in the assessment of clients referred for help with anger problems.

RESULTS

The PAC had good consistency and test-retest reliability, and the total score on the four cognitive dimensions correlated significantly with anger ratings but not with impersonal measures of anger disposition. The predominant cognitions reported were perceptions of unfairness and helplessness. People with ID and university students were in most respects very similar in both the psychometric analyses and the content analyses of their verbal responses. The PAC had high acceptability both to people with ID and to clinicians.

CONCLUSIONS

The PAC may be a useful instrument for both clinical and research purposes. Personal relevance and the conversational mode of administration are particular strengths.

Predictive validity of the HCR-20 for inpatient aggression: the effect of intellectual disability on accuracy

BACKGROUND

People with intellectual disability (ID) account for a large proportion of aggressive incidents in secure and forensic psychiatric services. Although the Historical, Clinical, Risk Management 20 (HCR-20) has good predictive validity in inpatient settings, it does not perform equally in all groups and there is little evidence for its efficacy in those with ID.

METHOD

A pseudo-prospective cohort study of the predictive efficacy of the HCR-20 for those with ID (n = 109) was conducted in a UK secure mental health setting using routinely collected risk data. Performance of the HCR-20 in the ID group was compared with a comparison group of adult inpatients without an ID (n = 504). Analysis controlled for potential covariates including security level, length of stay, gender and diagnosis.

RESULTS

The HCR-20 total score was a significant predictor of any aggression and of physical aggression for both groups, although the area under the curve values did not reach the threshold for a large effect size. The clinical subscale performed significantly better in those without an ID compared with those with. The ID group had a greater number of relevant historical and risk management items. The clinicians' summary judgment significantly predicted both types of aggressive outcomes in the ID group, but did not predict either in those without an ID.

CONCLUSIONS

This study demonstrates that, after controlling for a range of potential covariates, the HCR-20 is a significant predictor of inpatient aggression in people with an ID and performs as well as for a comparison group of mentally disordered individuals without ID. The potency of HCR-20 subscales and items varied between the ID and comparison groups suggesting important target areas for improved prediction and risk management interventions in those with ID.

Specialist group therapy for psychological factors associated with firesetting: Evidence of a treatment effect from a non-randomized trial with male prisoners

Despite huge societal costs associated with firesetting, no standardized therapy has been developed to address this hugely damaging behavior. This study reports the evaluation of the first standardized CBT group designed specifically to target deliberate firesetting in male prisoners (the Firesetting Intervention Programme for Prisoners; FIPP). Fifty-four male prisoners who had set a deliberate fire were referred for FIPP treatment by their prison establishment and psychologically assessed at baseline, immediately post treatment, and three-months post treatment. Prisoners who were treatment eligible yet resided at prison establishments not identified for FIPP treatment were recruited as Treatment as Usual controls and tested at equivalent time-points. Results showed that FIPP participants improved on one of three primary outcomes (i.e., problematic fire interest and associations with fire), and made some improvement on secondary outcomes (i.e., attitudes towards violence and antisocial attitudes) post treatment relative to controls. Most notable gains were made on the primary outcome of fire interest and associations with fire and individuals who gained in this area tended to self-report more serious firesetting behavior. FIPP participants maintained all key improvements at three-month follow up. These outcomes suggest that specialist CBT should be targeted at those holding the most serious firesetting history.

Maternal thoughts of harm in response to infant crying: an experimental analysis

Ninety-eight mothers of healthy firstborn infants 0 to 6 months old were randomly assigned to listen to 10-min of infant crying or infant cooing while continuously rating subjective feelings of frustration. Participants completed pre-test measures of depressed mood, empathy, and trait anger and post-test measures of infant-related harm thoughts, negative and positive emotions, and urge to comfort and to flee. Twenty-three (23.5 %) participants endorsed unwanted thoughts of active harm (e.g., throwing, yelling at, shaking the infant). Women in the cry condition were more likely than women in the coo condition to report thoughts of harm. Women in the cry condition who endorsed thoughts of harm reported higher frustration levels over the 10 min of crying, higher levels of post-test negative emotions, and stronger urges to flee the infant but not stronger urges to comfort the infant. Trait anger and personal distress empathy predicted the occurrence of unwanted thoughts of infant harm, whereas negative mood did not. Unwanted, intrusive, infant-related thoughts of harm may be triggered by prolonged infant crying, are predicted by personal distress empathy and a tendency to experience anger, and are associated with higher frustration, negative emotions, and the urge to escape the infant.

The relationship between maltreatment victimisation and sexual and violent offending: differences between adolescent offenders with and without intellectual disability

BACKGROUND

Juveniles with intellectual disabilities (ID) are more often victims of maltreatment and more often perpetrators of abuse than juveniles without ID. Because previous research on the relationship between maltreatment victimisation and subsequent offending behaviour was primarily performed in non-disabled samples, the present study aimed to examine differences between juvenile offenders with and without ID in the relationship between maltreatment victimisation and sexual and violent offending.

METHOD

The sample consisted of juvenile offenders with ID (n = 102) and without ID (n = 526) who appeared before the courts for a criminal act and for whom the Washington State Juvenile Court Assessment (WSJCA) was completed. Pearson correlation coefficients were calculated to determine the strength of the relationship between maltreatment and offending, Fisher's z tests were calculated to assess the significance of the differences between the two groups in the strength of the correlations, and multiple logistic regression analyses were performed to examine the unique contribution of maltreatment victimisation to the prediction of violent and sexual offending.

RESULTS

Seventy per cent of the juvenile offenders with ID and 42% of the juvenile offenders without ID had experienced abuse and/or neglect. Both sexual and violent offending were more common in juvenile offenders with ID than in juvenile offenders without ID. Moreover, the relationship between different forms of maltreatment and sexual offending was stronger in juvenile offenders with ID than in juvenile offenders without ID.

CONCLUSIONS

Given the high rates of abuse and neglect victimisation and the strength of the association between victimisation and sexual offending, especially in juvenile offenders with ID, treatment should focus on potential trauma and other problems associated with the abuse.

A non-randomised controlled trial of the R&R2MHP cognitive skills program in high risk male offenders with severe mental illness

BACKGROUND

The growing popularity of offending behavior programs has led to the interest of whether such programs are effective with mentally disordered offenders. This study aimed to evaluate the effectiveness of the Reasoning and Rehabilitation program adapted for offenders with severe mental illness (R&R2 MHP).

METHODS

A sample of 59 adult high risk males detained in a high secure hospital completed questionnaires at baseline and post treatment to assess violent attitudes, anger, coping processes and social problem-solving. An informant measure of social and psychological functioning, including disruptive behavior, was completed by staff at the same time. The data of 30 patients who participated in the group condition were compared using intention to treat analysis with 29 controls who received treatment as usual.

RESULTS

80% of group participants completed the program. In contrast to controls, significant medium-large treatment effects were found at outcome on self-reported measures of violent attitudes, social problem-solving and coping processes. Improvements were endorsed by informant ratings of disruptive behavior, social and psychological functioning.

CONCLUSIONS

The R&R2MHP had a comparatively low dropout rate and was effective in a sample of high risk mentally disordered offenders requiring detention in high security. Future research should use a randomized controlled design.

TRIAL REGISTRATION

Current Controlled Trials ACTRN12613000216718.

Group-based cognitive-behavioural anger management for people with mild to moderate intellectual disabilities: cluster randomised controlled trial

BACKGROUND

Many people with intellectual disabilities find it hard to control their anger and this often leads to aggression which can have serious consequences, such as exclusion from mainstream services and the need for potentially more expensive emergency placements.

AIMS

To evaluate the effectiveness of a cognitive-behavioural therapy (CBT) intervention for anger management in people with intellectual disabilities.

METHOD

A cluster-randomised trial of group-based 12-week CBT, which took place in day services for people with intellectual disabilities and was delivered by care staff using a treatment manual. Participants were 179 service users identified as having problems with anger control randomly assigned to either anger management or treatment as usual. Assessments were conducted before the intervention, and at 16 weeks and 10 months after randomisation (trial registration: ISRCTN37509773).

RESULTS

The intervention had only a small, and non-significant, effect on participants' reports of anger on the Provocation Index, the primary outcome measure (mean difference 2.8, 95% CI -1.7 to 7.4 at 10 months). However, keyworker Provocation Index ratings were significantly lower in both follow-up assessments, as were service-user ratings on another self-report anger measure based on personally salient triggers. Both service users and their keyworkers reported greater usage of anger coping skills at both follow-up assessments and keyworkers and home carers reported lower levels of challenging behaviour.

CONCLUSIONS

The intervention was effective in improving anger control by people with intellectual disabilities. It provides evidence of the effectiveness of a CBT intervention for this client group and demonstrates that the staff who work with them can be trained and supervised to deliver such an intervention with reasonable fidelity.

Angry affect and violence in the context of a psychotic illness: a systematic review and meta-analysis of the literature

A small but significant relationship between schizophrenia and violence is well established, but not yet fully explained. Research has highlighted anger as an important factor in precipitating actual violence in general and psychiatric populations. However, anger has not been extensively studied as a risk factor for violence in people with schizophrenia and related psychoses. We evaluated published evidence on the relationship between anger and violence in patients with schizophrenia and related psychoses by means of a systematic review of the literature. A search of main online databases from inception till January 2012 was performed and supplemented with correspondence with authors and data available online. 11 studies which measured angry affect in patients with schizophrenia who had been violent were included in the review. 5 studies with a total of 510 individuals had anger data that were suitable to be pooled in a meta-analysis in form of standardised mean difference values comparing the anger scores of the non-violent groups with violent groups. All the studies included showed significantly higher scores for anger in the violent group compared with the non-violent group with the pooled result expressed as standardised mean difference of 0.74 95% CI (0.53, 0.94) and the Z value for overall effect=7.01. The studies not included in the meta-analysis which looked at 610 individuals, were analysed descriptively and all of them reported higher scores for anger for individuals with schizophrenia who acted violently. There is a consistency of significant association between angry affect and violent behaviour in the context of psychotic illness across various study designs, settings and populations. Theoretical support already exists for this relationship and this review lends further support to explore this relationship further.

A brief screening instrument for emotionally unstable and dissocial personality disorder in male offenders with intellectual disabilities

Personality disorder is prevalent among offenders with intellectual disabilities (ID), and it is associated with their risk for violence and recurrent offending behaviour. A new staff-rated instrument, the Personality Disorder Characteristics Checklist (PDCC), designed to screen for ICD-10 dissocial and emotionally unstable personality characteristics was evaluated for its reliability and validity, as applied to 129 male forensic patients with ID. Internal consistency and test-retest reliability were very good. Supportive evidence for concurrent and discriminant validity was obtained in conjunction with an established staff-rated instrument, but not for patient self-report measures. Construct validity support was found for the PDCC in association with violent offence and hospital assault history and in significantly accounting for the number of physical assaults in hospital, controlling for multiple covariates. Results for the new measure were favourable in comparison to established instruments. It clinical utility for treatment planning and for the management of risk is discussed.

Differences between juvenile offenders with and without intellectual disability in offense type and risk factors

The present study aimed to examine differences between American juvenile offenders with and without intellectual disability (ID) in offense type and risk factors. The sample consisted of adolescents with ID (n=102) and without ID (n=526) who appeared before the courts for a criminal act and for whom the Washington State Juvenile Court Assessment (WSJCA) was completed. Results showed that adolescents with ID had committed more offenses against persons compared to adolescents without ID. Few differences in risk factors were found between juvenile offenders with and without ID in the domains of school, family and use of free time. Juvenile offenders without ID more often had problems in the relationship and alcohol/drugs domain, whereas juveniles with ID more often experienced problems in the domains of attitude, aggression and skills.

The Affective Reactivity Index: a concise irritability scale for clinical and research settings

BACKGROUND

Irritable mood has recently become a matter of intense scientific interest. Here, we present data from two samples, one from the United States and the other from the United Kingdom, demonstrating the clinical and research utility of the parent- and self-report forms of the Affective Reactivity Index (ARI), a concise dimensional measure of irritability.

METHODS

The US sample (n = 218) consisted of children and adolescents recruited at the National Institute of Mental Health meeting criteria for bipolar disorder (BD, n = 39), severe mood dysregulation (SMD, n = 67), children at family risk for BD (n = 35), or were healthy volunteers (n = 77). The UK sample (n = 88) was comprised of children from a generic mental health setting and healthy volunteers from primary and secondary schools.

RESULTS

Parent- and self-report scales of the ARI showed excellent internal consistencies and formed a single factor in the two samples. In the US sample, the ARI showed a gradation with irritability significantly increasing from healthy volunteers through to SMD. Irritability was significantly higher in SMD than in BD by parent-report, but this did not reach significance by self-report. In the UK sample, parent-rated irritability was differentially related to emotional problems.

CONCLUSIONS

Irritability can be measured using a concise instrument both in a highly specialized US, as well as a general UK child mental health setting.

The Lancaster and Northgate Trauma Scales (LANTS): the development and psychometric properties of a measure of trauma for people with mild to moderate intellectual disabilities

People with intellectual disabilities are exposed to a high number of adverse life events, and evidence supports a link between the experience of adverse life events and trauma. Interventions for trauma have been found to be efficacious if case recognition can be facilitated. However to date there are no psychometrically validated measures of trauma for people with intellectual disabilities. This study describes the development of the Lancaster and Northgate Trauma Scales (LANTS), which comprise a self-report and an informant measure of the effects of traumatic life events on people with intellectual disabilities. The pool of items for the measures was created via a systematic review, and consultation with key stakeholders. 99 service users and 88 staff completed the LANTS measures during a pilot. The 29-item self-report LANTS and the 43-item informant LANTS were found to have good psychometric properties, including internal and test retest reliability, plus convergent and construct validity. The findings suggest the LANTS are promising trauma screening tools for use in clinical and research settings.

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.

General and maladaptive traits and anger in a combined forensic psychiatric and general population sample

The present study examines the associations between anger and general and maladaptive traits in a combined forensic psychiatric and community sample of men. Thirty-four male forensic psychiatric patients and 219 men from the general population completed the Novaco Anger Scale (NAS; Novaco, 1994), the NEO-PI-R (Costa & McCrae, 1992), the ADP-IV (Schotte & De Doncker, 1994) and the VKP (Duijsens, Haringsma, & EurelingsBontekoe, 1999) at two measurement occasions with a one-year interval. The results of a series of multiple regression analyses showed that general and maladaptive traits accounted for a substantial amount of variance in anger scores. Neuroticism, Agreeableness and Externalizing traits were most prominent in the prediction of anger, while Conscientiousness was acting as a suppressor variable in the regression models. Strengths and limitations of the present study and implications for further research and clinical practice are discussed.

Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2-year retrospective audit

Seclusion with or without restraint is a measure used to manage patients with challenging behaviours. Although controversial, the intervention remains poorly documented, especially in Canadian psychiatric hospitals. The purpose of this study is to assess the prevalence of the measure and identify any correlated demographic characteristics and psychiatric disorders. Episodes of seclusion with or without restraint were extracted from a computerized, hospital-based system introduced specifically to track such interventions. Of 2721 patients hospitalized during that time, 23.2% (n = 632) were secluded with or without restraint, and 17.5% (n = 476) were secluded with restraint. Younger age, schizophrenia or other psychosis, bipolar and personality disorder, and longer stay in hospital are predictors of an episode of seclusion with or without restraint. Younger age, bipolar and personality disorders and a longer stay in hospital are predictors of an episode of seclusion with restraint. For patients who spent longer in seclusion and under restraint, there is a positive association with longer stay in hospital. In this inpatient psychiatric facility, seclusion with or without restraint thus appears to be common. More research is warranted to better identify the principal factors associated with seclusion and restraint and help reduce resort to these measures.

Individual cognitive-behavioural anger treatment for people with mild-borderline intellectual disabilities and histories of aggression: A controlled trial

OBJECTIVES

Anger is a significant predictor and activator of violent behaviour in patients living in institutional settings. There is some evidence for the value of cognitive-behavioural treatments for anger problems with people with intellectual disabilities. In this study, a newly designed treatment targeted at anger disposition, reactivity, and control was provided to intellectually disabled offenders with aggression histories living in secure settings.

DESIGN

About forty detained patients with mild-borderline intellectual disabilities and histories of serious aggression were allocated to specially modified cognitive-behavioural anger treatment (AT group) or to routine care waiting-list control (RC group) conditions.

METHODS

AT group participants received 18 sessions of individual treatment. The AT and RC groups were assessed simultaneously at 4 time points: screen, pre- and post-treatment, and at 4-month follow-up using a range of self- and staff-rated anger measures. The effectiveness of the treatment was evaluated using ANCOVA linear trend analyses of group differences on the main outcome measures.

RESULTS

The AT group's self-reported anger scores on a number of measures were significantly lower following treatment, compared with the RC wait-list condition, and these improvements were maintained at follow-up. Limited evidence for the effectiveness of treatment was provided by staffs' ratings of patient behaviour post-treatment.

CONCLUSIONS

Detained men with mild-moderate intellectual disabilities and histories of severe aggression can successfully engage in, and benefit from, an intensive individual cognitive-behavioural anger treatment that also appears to have beneficial systemic effects.

Habitual Goals and Strategies in Anger Regulation

The article presents two studies done with the Anger-Related Reactions and Goals Inventory (ARGI) combining the assessment of functional and dysfunctional anger-related reactions with the goals that people pursue in regulating interpersonal anger. Study 1 (N = 756) corroborated the questionnaire’s psychometric properties and factorial structure. Correlations with indicators for psychosocial well-being, trait anger, and the Big Five dimensions were largely in line with our predictions. Study 2 documented the convergence between self-reports (N = 104) and reports of two knowledgeable informants (N = 188), in particular for the dysfunctional reactions. We conclude that the ARGI is a reliable and valid questionnaire that taps into facets of anger regulation that are of high relevance for research on the consequences of anger for health and well-being.

Reliability and Validity of the Novaco Anger Scale and Provocation Inventory (NAS-PI) and State-Trait Anger Expression Inventory-2 (STAXI-2) in Hispanic and Non-Hispanic White Student Samples

This project tested the State-Trait Anger Expression Inventory—2 (STAXI-2) and the Novaco Anger Scale—Provocation Inventory (NAS-PI) in a sample of U.S. Hispanic ( n = 257) and U.S. non-Hispanic White ( n = 246) undergraduate students. Internal consistency, subscale correlations, convergent validity with the Multidimensional Anger Inventory (MAI), and predictive validity were all analyzed. Across ethnic groups, all major subscales demonstrated adequate internal consistency reliability. Correlations between the subscales were strong for both groups within each measure and with the subscales of the other measure. In predicting PI scores, there was no evidence of intercept invariance across the ethnic groups and no evidence of slope invariance when either measure was used as a predictor. Results suggest that both measures are valid for use in Hispanic samples.

Psychometric Evaluation of a Dutch Version of the Dimensions of Anger Reactions

Two studies were conducted to investigate the psychometric properties of a Dutch translation of the Dimensions of Anger Reactions, a brief test to measure anger disposition. In the first study, the factor structure, internal consistency, and validity of the scale were examined in a sample of 97 students. Factor analysis essentially yielded one factor, although further inspection found some evidence for a two-factor structure referring to “anger response” and “impairment.” The internal consistency was acceptable, and convergent and divergent validities were supported by a theoretically meaningful pattern of correlations with other self-report measures, such as the Aggression Questionnaire, Barrat's Impulsivity Scale–11, and the Symptom Checklist–90. In a second study, the test-retest reliability of the scale was examined in a separate sample of 37 students. A correlation coeffcient of .84 was found, supporting the reliability of the scale. Altogether, it can be concluded that the Dutch Dimensions of Anger Reactions seems to be reliable and valid for assessing anger disposition.

Predicting short-term institutional aggression in forensic patients: a multi-trait method for understanding subtypes of aggression

Accurately predicting inpatient aggression is an important endeavor. The current study investigated inpatient aggression over a six-month time period in a sample of 152 male forensic patients. We assessed constructs of psychopathy, anger, and active symptoms of mental illness and tested their ability to predict reactive and instrumental aggression. Across all levels of analyses, anger and active symptoms of mental illness predicted reactive aggression. Traits of psychopathy, which demonstrated no relationship to reactive aggression, were a robust predictor of instrumental aggression. This study (a) reestablishes psychopathy as a clinically useful construct in predicting inpatient instrumental aggression, (b) provides some validation for the reactive/instrumental aggression paradigm in forensic inpatients, and (c) makes recommendations for integrating risk assessment results into treatment interventions.

Prevalence, characteristics and causes of aggressive behaviour observed within a neurobehavioural rehabilitation service: Predictors and implications for management

PRIMARY OBJECTIVE

To describe the characteristics and determinants of aggressive behaviour observed within a neurobehavioural unit.

RESEARCH DESIGN

Statistical analysis of a database of routinely administered clinical measures, including the Overt Aggression Scale-Modified for Neurorehabilitation.

METHODS AND PROCEDURES

Records of aggressive behaviour shown by 108 patients over 14 days were studied. Patient characteristics were also captured using 23 items from the Rehabilitation Institute of Chicago-Functional Assessment Scale. Four factors were identified: 'communication', 'cognition/function', 'neurobehavioural disability' and 'mood & self-esteem'. Relationships between patient characteristics, external factors and their interactions with aggression were examined.

MAIN OUTCOMES AND RESULTS

Many (5548) episodes of aggression were recorded. Whilst most comprised verbal aggression, 729 physical assaults were made on others. Aggressive behaviour typically followed staff prompting or no obvious antecedent. Medical intervention was rare, most aggression was managed by staff not reinforcing this behaviour. Over 80% of physical assaults were made by people rated as having severe symptoms of neurobehavioural disability and poor communication.

CONCLUSIONS

Neurobehavioural units require sufficient staff resources to engage patients in purposeful activities as these were associated with the least severe aggression. Despite increased OAS-MNR usage, a standardized methodology for investigating aggression is required to ensure compatibility between datasets.

Assessing anger in people with intellectual disability

BACKGROUND

There is a growing interest in the use of cognitive approaches for the treatment of psychological difficulties with people who have intellectual disability. The aim of the present study was to investigate the properties of an anger inventory, the relationship between self-reported and staff-reported levels of anger, and the relationship between different staff measures.

METHOD

Two studies are described that use self-report and staff-report measures. The first study employs a cross sectional design and the second, a longitudinal design.

RESULTS

No relationship was found between self-reported and staff-reported levels of anger on the first measurement occasion, but on the second measurement occasion after some intervention a significant relationship was found. If staff had accompanied individuals during an intervention a larger correlation was found.

CONCLUSION

These results suggest that staff may require specific training or exposure to a therapeutic environment before they can predict the response of people with intellectual disability on the anger inventory. This suggests that involvement of care staff in interventions may be useful therapeutically.

Anger and assaultiveness of male forensic patients with developmental disabilities: links to volatile parents

This study with 107 male forensic patients with developmental disabilities investigated whether exposure to parental anger and aggression was related to anger and assaultiveness in a hospital, controlling for background variables. Patient anger and aggression were assessed by self-report, staff-ratings, and archival records. Exposure to parental anger/aggression, assessed by a clinical interview, was significantly related to patient self-reported anger, staff-rated anger and aggression, and physical assaults in hospital, controlling for age, intelligence quotient, length of hospital stay, violent offense history, and childhood physical abuse. Results are consonant with previous findings concerning detrimental effects of witnessing parental violence and with the theory on acquisition of cognitive scripts for aggression. Implications for clinical assessment and cognitive restructuring in anger treatment are discussed.

Personality disorder and offending in people with learning disabilities

This article reviews the literature on personality disorder in offenders with learning disabilities, using Medline, PsychoInfo and CINAHL databases, and search terms ‘offending’, ‘personality disorder and intellectual disabilities’, ‘learning disabilities’ and related terms. Methods of defining offending population, personality disorder and learning disabilities vary greatly, and few studies focus specifically on personality disorder, learning disability and offending. The definition of learning disability often encompasses both borderline learning disability and low average intelligence. Personality disorder, especially anti‐social personality disorder, is prevalent in offenders with learning disabilities, but less than in the general population, and is associated with higher levels of security and poorer outcomes. The study concludes that there is a continuum of offenders with borderline and mild learning disabilities, reflected in learning disability forensic services.