Using Anger

Assessment in Children
and Adolescents to
Develop Treatment Plans

Raymond DiGiuseppe, Ph.D., D.Sc., ABPP

St. John's University
and
The Albert Ellis Institute
 Anger Assessment
 1) Total scale scores may be in the normal range
yet the person may experience a clinical problem
with some aspects of anger. Total anger scores
may not be as informative.
 2) Since people think anger is not a problem, they
may not store all of the information together.
Open-ended questions may not be as helpful as is
usually the case as in other disorders.
 Test
The Aggression Questionnaire (AQ)
Buss & Perry (1992)
Anger Inventory (NI) Novaco (1977)
Anger Self-Report (ASR) Zelin,
Adler & Myerson (1972)  awareness and expression of aggression.
Attitude Towards Guns and
Violence (AGVQ) Shapiro (1997)
Becomes Angry Scale (BAS)
Siegel (1984)
Type of Test
Self-report measure of aggression, including physical aggression,
An 80-item 5-point Likert Scale that was developed as an index of
anger reactions to provoking incidents.
A 64-item Likert type scale constructed to differentiate between the
A 26-item instrument that measures violence-related attitudes.
A 19-item rating scale that assesses the frequency of anger expression
as well as the range of situations that will evoke anger.

Buss-Durkee Hostility Inventory A self-report multidimensional test that was developed to assess
(BDHI) Buss & Durkee (1957)  various aspects of hostility. 
Child Self-Control Rating Scale A 33-item 4-point scale. It uses an alternative question format. It is
(CSCRS) Rohrbeck, Azar & Wagner intended to supplement traditional teacher/parent perspectives on
(1991) children's self-control.
Conners-Wells' Adolescent Self- An 87 item Likert response scale. Measure of psychopathology,
Report Scale: Long Form (CASS:L) specifically targeting ADHD. Anger Control Problems is one of ten
Conners & Wells (1997) subscales. It is appropriate for youths 12-17.
MMPI-A Hathaway, McKinley & the
Adolescent Project Committee (1992)
Multidimensional Anger Inventory
(MAI) Siegel (1986)
Multidimensional School Anger
Inventory (MSAI) Smith, Furlong,
Bates & Laughlin (1998) 
Novaco Anger Inventory (NAS)
Novaco (1994)  provocations, cognitions, emotional arousal, and behaviors elicited by
The Pediatric Anger Expression
Scale (PAES) Jacobs, Phelps & Rohrs (1989)
Reaction Inventory (RI)
Evans & Stangeland (1971)  individual under specific situations. Subjects respond on a 5 pt. scale
S-R Inventory of Hostility Jaderlund
& Waldron (1968)
State-Trait Anger Expression
Inventory-2 Spielberger (1994)
The Teacher's Self-Control Rating
Scale (TSCRS) Humphreys (1982)
A 478-item true/false objective measure of psychopathology. Anger
and Cynicism are two of the fifteen content scales. It is intended for
adolescents ages 14-18.
A self-report test of the multidimensional nature of anger.
A 31-item Likert response scale developed to measure affective,
cognitive, and behavioral components of anger.
A self-report measure designed to assess the environmental
anger.
A 15-item self-report measure designed to assess anger as a
multidimensional construct.
A 76 item questionnaire developed to measure anger expressed by an
from "not at all" to "very much."
A 5 pt. Likert type scale containing 14 situations considered to be
frustrating and to evoke anger.
Provides measures of the experience, expression, and control of anger,
measured by 2 components: State and trait anger for adolescents and
adults.
A 15-item 5-point Likert teacher rating scale designed to assess school
behavior problems and self-control.
 Anger Disorder Scale

Multi-dimensional nature: 5 Domains and 18

Subscales.
Each factor or sub-scale has implications for
treatment and represents an aspect of
anger observed in clients.
The number of sub-scales reflects our beliefs
concerning what a clinician should know
to plan effective treatment.
 Anger Disorder Scale

Behavior Domain
< Verbal aggression
< Physical aggression
< Passive aggression
< Indirect aggression
< Relational aggression
< Anger in
Arousal Domain
< Duration of Axis I Problem
< Episode Length
< Physiological reactivity
 Anger Disorder Scale
Cognitive Domain
< Rumination
< Impulsivity
< Suspiciousness
< Resentment
Provocations
< Hurt / Social Rejection
< Scope of anger
 Anger Disorder Scale
Motives Domain
• Coercion
• Revenge
• Tension Reduction
Higher Order Factor Score
• Verbal Expression
• Anger In
• Vengeance
 Anger Disorder Scale

This scale clearly distinguishes Angry clients

and forensic samples from:
– Normal controls
– General Psychotherapy Outpatients
– Child & Adolescent Version presently being
normed.
Published by MultiHealth Systems
Toronto, Ontario Canada
 Anger Disorder Scale –
Youth Version
 Factor structure is very similar
 Impulsivity and rumination do not separate into
different factors but merge as one.
 Physical, verbal, indirect, and relational aggression load
together as one factor.
 No sex differences for Relational Aggression.
 Tension reduction is a weak factor in adults but much
stronger in adolescent, This was confirmed in H.
Luttinger’s dissertation with a different method.
 Cluster Analysis
 Ward's Method
 Squared Euclidian Distances
 An Inverse Scree test of the Agglomeration
values created the Clustering Analysis.
 13 clusters were identified as the best fit.
 We analyzed 12,14 & 15 cluster solutions.
 We then used Discriminate Function Analysis to
confirm the results (Percent of accurate
classification).
 Cluster Analysis
 This uses the subscales to predict cluster
membership. Also, Kappa coefficients
were used to see which solution produced
the most reliable categories.
 More clusters produced different levels of
the same patterns.
 Fewer clusters missed some important
groups.
 Table 2

Inverse Scree of Aggolmoration Values

3000000

2500000
Mean D

2000000

X-13 Cluster Form Here

1500000

960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982
cluster
 Anger In Clusters
• Several clusters characterized by Anger In.
• They had some elevations on Passive
Aggression.
• Anger-In is characterized by Suspiciousness
and resentment.
• Triggered by social rejection.
Figure 15.6

The Resentful, Vengeful, High Intesity, Anger-In Profile

80

75

70

65
Mean

60

55

50

45

40
 Non Confrontational Anger

 Not all aggression is impulsive, or

confrontational.
 This cluster is vengeful, ruminative and non
impulsive.
 The dominance of the Instrumental /
Affective-Impulsive aggression distinction
has blinded us to planned anger motivated
aggression.
 Cluster 9 of 13

NonConfrontational Vengeance Profile

80

75

70

65
M ean

60

55

50

45

40
Verbal not Relational Aggression
 Here is a subtype with high coercion,
revenge and verbal arguing.

 This is a profile most likely reserved for the

family.
 Cluster 12 of 13

Verbal, Not Relational Aggressive Profile

90

85

80

75
M ean

70

65

60

55

50
 Pure IED?
 We get a group that is impulsively
aggressive with AVERAGE TRAIT
ANGER.
 Furlong and Smith find a group like this is
boys.
Figure 15.2

The Poly-Aggression with Moderate Anger Profile

80

75

70
T S c o re s

65

60

55

50

45

40
High Anger and High Aggression
 Many people have both disturbed anger and
aggression.
 Cluster 13 of 13

Extreme Anger and Aggression Cluster

110

105

100

95

90
Mean

85

80

75

70

65

60
 What Diagnosis?
 Several DSM include anger but it is neither
necessary nor sufficient to reach the
diagnosis.
– Oppositional Defiant Disorder
– Conduct Disorder
– Borderline PD
 What Diagnosis?
 Other Aggressive or Impulsive Diagnoses
include
– IED
– Bipolar
 Anger and Impulse or Manic
Disorders
 Anger is often considered to be an impulse
disorder, like IED, or part of mania as
proposed by Kraeplin and Freud.
 Do these disorder account for those with
anger symptoms?
 No.
 What Diagnosis?
 Anger symptoms over lap the most with ODD
 Research indicates that When therapists are asked
to pick an externalized disorders that they are
treating, and asked what best diagnosis or
descriptor identifies the child, ODD, CD, ADHD,
BPD or Anger problems. They rate “anger
problem” the highest.
 So We may want an ANGER diagnosis rather than
ODD.
Figure 3A. Diagnosis of Impulse Disorders & Anger, Out of 1774 Patients

350
N=315

300

250
Frequency

200

150

100

50

0
A IE Bi Bi A A A A A A A
ng D p po D ny ng ng ng ng ng
er O ol D er e e er er
nl ar l ar on Su r& r&
O y I II l b & & an
nl O O y st IE B B A d
y nl nl an D ip ip D Su
y y ce ol ol D
ar ar bs
D I I I ta
X n ce
D
X
Figure 3. Anger Patients & Comorbid Impulse Disorders, N = 459.

70% N=315

60%

50%
P e rc e n t

40%

30%

20%

10%

0%
Anger Only Anger & IED Anger & Anger & Anger & ADD Anger and
Bipolar I Bipolar II Substance DX
 Anger and IED

Most people experience state anger when they

behave aggressively.
Some people have moderate trait anger but
explode and express anger aggressively when
they get angry.
For these few with IED this may be an adequate
category.
But most of those who meet criteria for IED are
angry.
 Anger and IED

IED is inadequate for most people with anger

symptoms.
Most IED and aggressive clients have high
trait anger when they aggress. Thus, they are
not adequately described by IED.
 Anger and Emotional
Disorders
 What about other disorders of excess affect
such as anxiety and mood or depressive
disorders?
 Do these disorders account for anger
symptoms?
 NO.
Figure 4. Frequency of Emotional Disorders and Anger Symptoms &
Comorbide Cases. N = 1774.

400

350

300
Count

250

200

150

100

50
No Affetive Anger Only Anxiety Depression Anger & Anger & Anxiety and All Three
Probllem Only Only Anxiety Depression Depression Emotions
Figure 4A. Percent of Patietns with Emotional Disorders, Anger Problems &
Comorbidity. N = 1774.

25%

20%

15%
Percent

10%

5%

0%
No Affetive Anger Only Anxiety Depression Anger & Anger & Anxiety and All Three
Probllem Only Only Anxiety Depression Depression Emotions
 Figure 4B. Clients with Anger Symptoms

with and without Other Emotional Disorders, N = 459.

50.0%

40.0%
P e rce n t

30.0%

20.0%

10.0%

0.0%
Anger Only Anger & Anxiety Anger & Depression All Three Emotions
Anger Anx Dep
 Anger and Emotional Disorders
Anger is comorbid more frequently with anxiety
than depression, despite the focus on depression.
Anger symptoms occur more frequently with
anxiety & depression.
Perhaps we need a disorder of excessive affect.
Anger without other disturbed affect occurs less
frequently than anxiety and depression do alone, but
still frequent enough to be a disorder in its own
right.
The most common comorbid Anxiety Disorder is
not GAD or PTSD.
It is Social Phobia.
 Diagnostic Criteria for Anger
Regulation and Expression Disorder

Either (1) or (2)

1 Significant angry affect as indicated by frequent,
intense, or enduring anger episodes that have
persisted for at least six-months. Two more of the
following characteristics are present during or
immediately following anger experiences:
Physical activation (e.g., increased heart rate, rapid breathing,
muscle tension, stomach related symptoms, headaches)
Rumination that interferes with concentration, task performance,
problem-solving, or decision-making
 Diagnostic Criteria for Anger
Regulation and Expression Disorder
Cognitive distortions (e.g., biased attributions regarding the
intentions of others; inflexible demanding view of others
unwanted behaviors, code of conduct, or typical inconveniences;
low tolerance for discordant events; condemnation or global
rating of others who engage in perceived transgressions)
Ineffective communication
Brooding or withdrawal
Subjective distress (e.g., awareness of negative consequences
associated with anger episodes, anger experiences perceived as
negative, additional negative feelings such as guilt, shame, or
regret follow anger episodes)
 Diagnostic Criteria for Anger
Regulation and Expression Disorder
– 2 A marked pattern of aggressive/expressive
behaviors associated with anger episodes.
Expressive patterns are out of proportion to the
triggering event. However, anger experiences
need not be frequent, of high intensity, or of
long duration. At least one of the following
expressive patterns is consistently related to
anger experiences:
 Diagnostic Criteria for Anger
Regulation and Expression Disorder
 Direct Aggression/Expression
 Aversive verbalizations (e.g., yelling, screaming, arguing nosily, criticizing,
using sarcasm, insulting)
 Physical aggression toward people (e.g., pushing, shoving, hitting, kicking,
throwing objects)
 Destruction of property
 Provocative bodily expression (negative gesticulation, menacing or
threatening movements, physical obstruction of others)
 Indirect Aggression/Expression
 Intentionally failing to meet obligations or live up to others’ expectations
 Covertly sabotaging (e.g., secretly destroying property, interfering with task
completion, creating problems for others)
 Disrupting or negatively influencing others’ social network (e.g., spreading
rumors, gossiping; defamation, excluding others from important activities)
 Diagnostic Criteria for ARED
B There is evidence of regular damage to
social or vocational relationships due to
the anger episodes or expressive patterns.
C The angry or expressive symptoms are not
better accounted for by another mental
disorder (e.g., Substance Use disorder,
Bipolar Disorder, Schizophrenia, or a
personality disorder) or medical condition.
 Diagnostic Criteria for ARED

 Three subtypes of ARED

– Primarily Expressive. Aggressive moderate
anger. Same as IED. Perhaps we have found
impulsively, moderately angry, non ruminative
patients.
– Primarily Subjective High Anger with Anger-
In only or non-confrontive aggression.
– Combined - High Anger and high aggression
 Primarily Subjective Anger
Subtype
 Treat the resentment, and suspiciousness.
 Treat the hurt and easily bruised ego.
 This group holds their anger in a lot and
they need new assertiveness skills
 Primarily Expressive Anger
Subtype
 Self control training and impulse control
training to not respond aggressively when
angered.
 Assertiveness skills to replace aggression.
Combined Angry and Aggressive
Subtype
 There may be two groups in here
– Verbal
– Confrontive aggressive
– Non Confrontive aggressive
– For the first coercion may be the motive and
treatment leads to acceptance of non control
Combined Angry and Aggressive
Subtype
 For the second tension reduction may be the
motive. Acceptance of the affect may be
the primary treatment strategy
 For the non confrontive and some
confrontive clients REVENEG is the
motive. Forgiveness is the treatment
 Contact Ray DiGiuseppe

Department of Psychology
St. John’s University
Jamaica, NY 11439
digiuser@stjohns.edu