Trilafon

ABSTRACT

Drawn from a day school for emotionally disturbed adolescents, seven students who scored in the clinical range on the Conduct subscale of the Conners Teacher Rating Scale took part in an anger management program. The program included psychoeducation, anger discrimination training, logging incidents of anger, and training in prosocial responses to anger. Pre-post assessments provided evidence of positive effects. The adolescents showed significant improvement on both the teacher (p [less than] .03) and the parent (p [less than].04) versions of the Conduct subscale. They also exhibited a trend toward fewer incidents of physical aggression (p [less than] .06). The implications of these findings for future research are discussed.

Perhaps no greater challenge faces the clinical and educational communities than to help troubled adolescents learn to cope with their angry feelings in a socially appropriate manner. Angry children may engage in antisocial behaviors, including acts of violence. Unfortunately, when children become aggressive at a young age, the tendency toward violent behavior seems to remain relatively stable (Fraser, 1996). Early, effective intervention is thus needed.

A growing number of researchers are addressing the needs of adolescents with anger difficulties. Feindler (1991, 1995; Feindler & Ecton, 1986; Feindler, Marriott, & Iwata, 1984) and Goldstein (1988; Goldstein & Glick, 1987) have focused on developing cognitive-behavioral skill-building approaches for helping a wide range of emotionally troubled adolescents (from the mildly anger-prone to the severely aggressive), in a variety of outpatient, public school, and institutional settings, to control anger. Their treatment efforts have included individual, group, and psychoeducational modalities. Results have been encouraging; adolescents acquired anger management skills and exhibited a reduction in the frequency and intensity of acting-out incidents.

Deffenbacher, Lynch, Oetting, and Kemper (1996) have investigated treatment specificity and efficacy. Anger-prone early adolescents attending regular schools, who were taught either cognitive coping skills or social skills, showed a reduction in inappropriate anger expression and an increase in controlled anger expression. Further, Nugent, Champlin, and Wiinimaki (1997) reported positive results when anger control techniques were taught to delinquent adolescents in a group home setting. In fact, the longer the training, the greater the reduction in antisocial, acting-out behavior.

According to Feindler and Ecton (1986), anger management training typically includes the following: (1) providing information on the cognitive and behavioral components of anger, (2) teaching cognitive and behavioral techniques to manage anger, and (3) facilitating the application of newly acquired skills. Specific skills, such as relaxation, assertiveness, anticipation, self-instruction, self-evaluation, role-play or rehearsal, and problem solving, are emphasized. In addition, participants are often encouraged to use a log, recording anger-provoking situations and assessing the degree to which anger was successfully managed.

A category of anger-prone adolescents that has not been studied sufficiently involves those who attend day schools for the emotionally disturbed. Consequently, the present study examined the impact of providing anger management training to small groups of adolescents in such a school. Students with clinically significant aggressive behavior were assessed by both teachers and parents before and after the intervention. Archival reports of aggressive incidents were also examined.

METHOD

Participants

Seven students in a day school for emotionally disturbed adolescents participated. They were assigned to anger management groups based on recommendations from teachers and clinicians, as well as self-referral. The groups were intentionally composed of students with both mild and severe anger control difficulties. All scored in the clinical range (above 65) on the Conduct subscale of the Conners Teachers Rating Scale (Conners, 1989).

Six of the students were male and one was female. Four were in the 14-15 age range, while three were in the 17-18 range. Six were Caucasian and one was Hispanic. Two students lived in intact, two-parent households, three lived in single-parent homes, one resided in a foster home, and one lived in a group home. In terms of socioeconomic status, five of the students qualified for subsidized lunches. Three were above average in IQ and four were average.

Their diagnoses covered a wide range of behavioral and affective disorders. Four were diagnosed with attention-deficit/hyperactivity disorder (for three, dystymic disorder was also part of the diagnosis, and for one, anxiety disorder was included). One student had the dual diagnosis of developmental disorder/conduct disorder, while another was diagnosed with bipolar disorder and borderline personality disorder. The diagnosis for the seventh student included intermittent explosive disorder, conduct disorder, and dysthymic disorder.

Three students were not on medication, including one for whom medication was recommended but who chose not to comply. One student was prescribed Trilafon, another Depakote. Two were prescribed both Haldol and Cogentin (along with either Prozac or clonidine).

Anger Management Program

Sessions were held weekly for ten weeks, and each session lasted thirty minutes. Two licensed clinical social workers, one male and one female, led the groups. The initial sessions set forth the psychoeducational concepts that are the foundation of the program (Feindler & Ecton, 1986; Goldstein & Glick, 1987; Kellner & Tutin, 1995). Thus, students were educated about the physiology of anger and were encouraged to identify the bodily signs of anger arousal. They were taught about "triggers" and were invited to reflect on the situations that caused them to become angry. They were introduced to the prosocial criteria for evaluating how they managed their anger (i.e., angry feelings are well-managed if violence and consequent punishment are avoided). Finally, group members were asked to provide examples of ways they handled anger and to determine the degree to which these behaviors met the prosocial criteria. Emphasis was placed on helping the adolescents understand that anger is a normal feeling that must be de alt with in an acceptable manner. In order to provide a bridge between the group experience and everyday life, they were encouraged to fill out daily anger logs in which they noted: (1) each anger-provoking incident, (2) the setting associated with the incident, (3) how the incident was handled, (4) the degree of anger, and (5) how well anger was managed.

Efforts were made to help students link the psychoeducational concepts to the techniques of anger management. For example, during discussions about the physiology of anger, students were shown relaxation, deep-breathing, and counting exercises. Analysis of cognitions that accompany angry emotions afforded the opportunity to teach the students how to substitute calming thoughts for those that prolong or intensify arousal. Moreover, anger-provoking incidents that had occurred between group meetings were analyzed using role-play. This enabled students to practice and receive praise for utilizing prosocial strategies. Self-evaluation was encouraged in an effort to help them internalize the prosocial criteria for anger management. Finally, in order to discourage oppositional behavior, students were given the opportunity to take turns being group leader. In addition to helping reduce disruptive acts, this leadership role enabled them to demonstrate their understanding of the principles of anger management, reinfor ced learning, and aided in the development of positive social skills and self-esteem. At the end of the program, each student was given a certificate of completion during a special group ceremony.

Dependent Variables

Three measures of student behavior were used. First, one week before the program began and one month after the program ended, teachers were asked to rate student behavior using the Conduct subscale of the Conners Teacher Rating Scale (Conners, 1989). This standardized instrument was selected because of its established validity in measuring conduct problems in children. It was hypothesized that after participation in the anger management group, students would receive improved conduct scores from their teachers.

Second, one week before the program began and six months after the program ended, parents were asked via telephone to rate their children's behavior using the Conduct subscale of the Conners Parent Rating Scale (Conners, 1989). Again, this well-established scale was used because of its documented validity. It was hypothesized that after participation in the anger management group, students would receive improved conduct scores from their parents.

Third, during both the six months before the program began and the six months after it ended, the number of incidents of physical aggression by participating students was counted (a system exists, entirely independent of the anger management program, to report any situation involving physical aggression to staff or peers). It was hypothesized that after participation in the anger management group, the number of incidents of physical aggression would decrease.

RESULTS

Conduct Subscale: Teacher Version

Prior to their participation in the anger management group, the students' mean score on the Conduct subscale of the Conners Teacher Rating Scale was 92.57. After participation, their mean score was 80.28. Their improvement was statistically significant (Walsh test, p [less than].03). In fact, every student's score either improved or stayed the same; no student received a worse score after completing the program.

Conduct Subscale: Parent Version

Before their participation in the anger management group, five of the students received a mean score of 81.00 on the Conduct subscale of the Conners Parent Rating Scale (ratings could not be obtained from parents of two of the students). After participation, their mean score was 65.00. According to the randomization test for matched pairs (pre-post), the students' improvement was statistically significant (p [less than].04), Again, the students' scores either improved or stayed the same; no student's score deteriorated.

Number of Incidents of Physical Aggression

During the six months prior to participation in the anger management group, the seven students averaged 1.28 physically aggressive incidents. During the six months after participation, the mean score was .28. According to the randomization test for matched pairs (pre-post), their improvement approached statistical significance (p [less than].06). Aggressive incidents decreased or stayed the same for all but one of the students.

DISCUSSION

This study examined the effects of an anger management program on the aggressive behavior of seven students attending a special day school. Teacher and parent ratings of their aggressive behavior, as well as documented incidents of physical aggression at school, were analyzed. Improvement was noted on all three measures, despite the fact that early adolescents with aggression problems often become more aggressive as they grow older (Elliott & Voss, 1974).

Although Conduct subscale scores for the majority of students remained in the clinical range after participation in the program (according to teacher ratings), it is nonetheless encouraging the positive change occurred. Clearly, more must be done. One option is to incorporate anger management training into the regular classroom experience of such students. This would allow for more intensive anger management skill development than that provided by once-a-week group treatment.

The parents also reported significant improvement in their children's conduct. Certainly, it is encouraging that these gains were reported six months after participation in the program. Maintenance of beneficial effects has been a concern (Feindler & Ecton, 1986; Goldstein & Glick, 1987; Nugent et al., 1997), especially since many youngsters do not receive support for continued use of the prosocial skills learned during treatment. Moreover, it is understandably difficult for them to apply these skills in the face of community, peer, and sometimes even family pressure to use aggression to solve interpersonal problems. Thus, a psychoeducational-based anger management program for parents and other caregivers, complementing the student program, should be considered.

Finally, future studies should measure the use of prosocial skills as well as the occurrence of conduct problems. Such an approach would provide insight into the anger management techniques that would best assist adolescents according to their specific diagnostic needs.

The authors are grateful to Jordan Pauker, Psy.D., Kim Daraghy-Ford, P. J. Madreperl, and Kevin Iglesias for their assistance in conducting this study.

Brenna H. Bry, Ph.D., Professor, Graduate School of Applied and Professional Psychology, Rutgers University.

REFERENCES

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Nugent, W., Champlin, D., & Wiinimaki, L. (1997). The effects of anger control training on adolescent antisocial behavior. Research on Social Work Practice, 7, 446-462.

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