Published for the British Institute of Learning Disabilities

Journal of Applied Research in Intellectual Disabilities 2013, 26, 410419

Different Factors Influence Self-Reports and

Third-Party Reports of Anger by Adults with
Intellectual Disabilities
John Rose*,, Paul Willner,, Jennifer Shead, Andrew Jahoda, David Gillespie**, Julia Townson**, Claire Lammie,
Christopher Woodgate, Biza Stenfert Kroese*, David Felce, Pamela MacMahon, Nikki Rose, Aimee Stimpson,
Jacqueline Nuttall** and Kerenza Hood**
*School of Psychology,University of Birmingham,Birmingham,UK; Black Country Foundation Partnership Trust,Stourbridge,UK; Psychology
Department,College of Human and Health Sciences,Swansea University,Swansea,UK; Directorate of Learning Disability Services,Abertawe Bro
Morgannwg University Health Board,Neath,UK; Institute of Health and Wellbeing,College of Medical, Veterinary and Life Sciences,University
of Glasgow,Glasgow,UK; **South East Wales Trials Unit,Institute of Primary Care & Public Health,School of Medicine,Cardiff University,
Cardiff,UK; Psychological Medicine and Neurology,School of Medicine,Cardiff University,Cardiff,UK

Accepted for publication 21 January 2013

Background Many people with intellectual disabilities
display high levels of anger, and cognitive-behavioural
anger management interventions are used routinely.
However, for these methods to be used optimally, a
better understanding is needed of different forms of
anger assessment. The aim of this study was to
investigate the relationship of a range of measures to
self- and carer reports of anger expression, including
instruments used to assess mental health and
challenging behaviour.
Method Adults with intellectual disabilities, who had
been identified as having problems with anger control,
their key-workers and home carers all rated the service
users trait anger, using parallel versions of the same
instrument (the Provocation Inventory). In addition,
service users completed a battery of mental health
assessments (the Glasgow Depression Scale, Glasgow
Anxiety Scale and Rosenberg Self-Esteem Scale), and
both groups of carers completed a battery of challenging
behaviour measures (the Hyperactivity and Irritability
domains of the Aberrant Behavior Checklist and the
Modified Overt Anger Scale).
Results Participants had high levels of mental health
problems (depression: 34%; anxiety: 73%) and severe
challenging behaviour (26%). Hierarchical linear regres-
sion analysis was used to explore the extent to which
anger ratings by the three groups of respondents were
predicted by demographic factors, mental health
measures and challenging behaviour measures. Older
service users rated themselves as less angry and were also
rated as less angry by home carers, but not by key-
workers. More intellectually able service users were rated
as more angry by both sets of carers, but not by the service
users themselves. Significantly, mental health status (but
not challenging behaviour) predicted service users self-
ratings of anger, whereas challenging behaviour (but not
mental health status) predicted carers ratings of service
users anger.
Conclusions Service users and their carers appear to use
different information when rating the service users
anger. Service users self-ratings reflect their internal
emotional state and mental health, as reflected by their
ratings of anxiety and depression, whereas staff rate
service users anger on the basis of overt behaviours, as
measured by challenging behaviour scales.
Keywords: anger, challenging behaviour, intellectual dis-
ability, mental health

as verbal and/or physical aggression (Taylor et al. 2005;

Introduction
Anger is a frequent problem for many people with
intellectual disabilities, and while many individuals are
able to manage anger appropriately, it is often expressed
Benson & Brooks 2008). Prevalence estimates for problem
anger among people with intellectual disabilities vary
between 11 and 27% (Rose et al. 2008). A recent review of
studies of aggressive challenging behaviour reported that

2013 John Wiley & Sons Ltd 10.1111/jar.12037


over 50% of people with intellectual disabilities display
some form of aggression (Benson & Brooks 2008).
Aggression resulting from uncontrolled anger can lead to
serious consequences, which include exclusion from
services, breakdown of residential placements and
involvement with the criminal justice system (Allen et al.
2007; Emerson et al. 2008; Mental Health Foundation
2008). Aggressive behaviour can also have an impact on
the psychological well-being of care staff (Jenkins et al.
1997) and the quality of care they provide (Rose et al.
1998).
Anger is an active area of therapeutic research. A
number of small trials have shown beneficial outcomes
of cognitive-behavioural interventions for people with
intellectual disabilities (Taylor et al. 2008; Willner 2007).
The evaluation of anger is usually by service users self-
reports (e.g. Taylor et al. 2002, 2004, 2005; Hagiliassis
et al. 2005; Rose et al. 2005, 2008, 2009). However, some
studies have used carer third-party reports instead of
(e.g. King et al. 1999; Rose 2010), or in addition to, self-
reports (e.g. Willner et al. 2002, 2005; Lindsay et al. 2004;
Willner 2007). The extent to which self- and third-party
reports of anger provide the same or different
information is unknown. However, there is reason to
suspect that they may, to some extent, reflect different
constructs. For example, Rose & Gerson (2009) found no
relationship between self- and staff-reported anger using
parallel forms of an anger provocation inventory, prior
to participating in an anger management programme.
(However, these measures were significantly correlated
afterwards if both the service users and their staff carers
participated in the intervention.) Earlier studies also
reported discrepancies relationship between self- and
staff-reported ratings of anger (Bramston & Fogarty
2000; Benson & Ivins, 1992) and challenging behaviour
(Voelker et al., 1990). Significant correlations have been
reported between staff ratings on an Anger Inventory
and a range of measures of challenging behaviour rated
by the same staff (Rose & Gerson 2009). However, self-
reports of anger on the same Anger Inventory have been
found to be related to change in self-reported depression
(Rose et al. 2000), suggesting an association between self-
reported anger and the self-report of other psychological
difficulties. Anger is closely related to depression and
other mental health problems both in the general
population (Painuly et al. 2005; Balsamo 2010; Mahon
et al. 2010) and in people with intellectual disabilities
(Davis et al. 1997; Hurley 2008).
While there is certainly some relationship between
service users mental health problems and their
challenging behaviour (Meins 1995; Moss et al. 2000),
2013 John Wiley & Sons Ltd, 26, 410419
Journal of Applied Research in Intellectual Disabilities 411
these findings point to the possibility that the
information used by carers when making third-party
ratings of service users anger may differ from that
informing service users own self-ratings. On the basis of
these earlier studies, we predicted that service users own
anger ratings would be related to other self-reports of
mental health status, but that carers anger ratings would
be related more strongly to the service users observable
challenging behaviour. Factors predictive of anger ratings
by service users and two groups of carers were identified
using hierarchical regression analyses. This method was
preferred to the simple linear regression analysis used in
earlier studies (Rose et al. 2005; Rose 2010) because the
study included several measures of both mental health
and challenging behaviour.
Methods
Multicentre ethical approval for the study was granted
by South East Wales Research Ethics Committee. R&D
approval was granted in all regions, with additi-
onal participation identification centre approval where
required.
Participants
The participants in this study were recruited to a cluster-
randomized trial of anger management, the outcomes of
which will be reported separately (Willner et al. 2011).
They were 181 service users (128 men and 53 women)
who attended one of 30 services providing day activities
for people with intellectual disabilities, located in the
English midlands, south Wales and central Scotland,
along with their key-workers (n = 124: 48 men and 76
women) and, where possible, a home carer (n = 127:
men 45 and women 82). The number of key-workers is
smaller than the number of service users because some
key-workers acted for more than one service user. The
median (IQR) age (years) of each group was as follows:
service users, 38 (2847); key-workers 46 (4052); home
carers 50 (3458). The participating services included 17
traditional local authority day services, 5 independent-
sector day services and 8 residential services that also
provided day activities for their residents. Most of the
service users lived in the family home (41%) or in
staffed/supported living arrangements (38%).
The inclusion criteria for the trial were that service
users were considered by their service to display
problem levels of anger and wished to learn to improve
their anger management, were able to provide consent
to participate in the trial and were assessed as able to
412 Journal of Applied Research in Intellectual Disabilities
complete Likert-type scales. Potential participants were
excluded if they were attending the service for a reason
other than a diagnosed intellectual disability or were
currently receiving or urgently requiring psychological
treatment for anger or aggression. Service users had a
median (IQR) Full Scale IQ of 57 (5362), as assessed by
the Wechsler Abbreviated Scale of Intelligence (WASI),
and a mean (SD) score of 85 (16) on the short version of
the Adaptive Behavior Scale, which converts to a full-
ABS score of 223, equivalent to the 75th percentile of
people with intellectual disabilities living in residential
or community care (Hatton et al. 2001).
Procedure
Assessments were conducted face-to-face by research
assistants who had no other contact with the respondents
service. All three groups of respondents completed the
Provocation Index (PI), a direct measure of felt response to
defined situations that might provoke anger that has
frequently been used with this service-user group (Novaco
1994; Taylor et al. 2005). It consists of a list of 25 different
situations that can evoke anger, each of which is rated on a
four-point scale (03) for the amount of anger evoked.
Scores on this measure have been shown to correlate with
staff-reported levels of aggression (Taylor et al. 2005).
Service users completed the following mental health
assessments: the Glasgow Depression and Anxiety Scales,
which are established measures of depression and
anxiety among people with an intellectual disability
(Cuthill et al. 2003; Mindham & Espie 2003), and an
adaptation of the Rosenberg Self-Esteem Scale for people
with an intellectual disability (Dagnan & Sandhu 1999).
Challenging behaviour was assessed by key-worker
and home-carer report using the Hyperactivity and
Irritability domain items of the Aberrant Behavior
Checklist (ABC) (Aman et al. 1985) and the Modified
Overt Aggression Scale (MOAS) (Oliver et al. 2007).
Key-workers also completed the Controllability Beliefs
Scale (CBS) (Dagnan et al. 2004), which measures their
attributions in respect of challenging behaviour.
Statistical analysis
The data reported are for participants for whom
complete data were available for all of the variables
included in the analyses (service users, n = 163; key-
workers, n = 113, reporting on 162 service users; home
carers, n = 114). Where a key-worker acted for more
than one service user, the data were treated as though
they were independent. Standard model diagnostics
were carried out for all reported analyses.
The analysis was in two stages. First, bivariate product
moment correlations (Pearson or Spearman, depending
on the distribution of the data) were computed for all
variables. Then, three hierarchical linear regression
analyses were conducted to predict service-user, key-
worker and home-carer PI scores. Variables were entered
in three blocks: demographic variables, mental health
measures and challenging behaviour measures. For
service users, the first block included age, gender and IQ;
for key-workers and home carers, the respondents age
was also included. The second block included the service
users ratings on the three mental health measures: GDS,
GAS and RSES. The third block included the three
challenging behaviour measures: ABC-H, ABC-I and
MOAS; key-worker ratings were used for the service user
and key-worker analyses, and home-carer ratings were
used for the home-carer analysis. On a visual inspection
of the residuals and the residuals plotted against the
predicted values, there appeared to be no obvious
outliers in the service-user and key-worker data sets.
There appeared to be one outlier in the home-carer data
set, but excluding this value did not change the
conclusions of the analysis. Multicollinearity checks,
using the variance inflation factor, did not identify
collinearity issues in any of the models tested.
Results
PI scores were similar to those observed in earlier
studies on a comparable population (Willner et al. 2005;
Willner 2007), with service users rating themselves
somewhat higher than they were rated by their key-
workers or home carers [mean (SD) PI scores: 44 (17),
33 (13), 30 (13), respectively; F(2,487) = 38.05, P < 0.001].
A relatively high proportion of service users displayed
significant levels of depression, with 34% of them scoring
at or above the cut-off value for clinical depression of 13
on the Glasgow Depression Scale (Cuthill et al. 2003). An
even higher proportion of service users displayed
significant anxiety symptoms, with 73% scoring at or
above the cut-off value for clinical anxiety of 13 on the
Glasgow Anxiety Scale (Mindham & Espie 2003).
In a previous work, severe challenging behaviour has
been defined by a criterion of either a combined score of
>30 on the ABC-H and ABC-I or >4 behaviours on these
two scales rated as a severe problem (i.e. at level 3)
(Robertson et al. 2004). 47 service users (26% of the
sample) met this criterion.
2013 John Wiley & Sons Ltd, 26, 410419

Correlations between clinical variables
Service-user PI ratings were only marginally correlated
with carer ratings (key-workers: r = 0.158, P = 0.044;
home carers: r = 0.174, P = 0.062), but the correlation
between the two carer ratings was much larger (r = 0.356,
P < 0.001), suggesting that key-workers and home carers
see service-user anger similar to one another, but there is
more divergence between carer ratings and service users
self-perception.
Service-user ratings on the three mental health meas-
ures were significantly intercorrelated (all P < 0.001). The
highest correlation was between the depression and
anxiety scores (GDS versus GAS: r = 0.697). Correlations
with self-esteem (RSES) were lower (r = 0.384, 0.302,
respectively).
Similarly, both key-worker and home-carer ratings on
the three challenging behaviour measures were strongly
intercorrelated (all r > 0.445, P < 0.001). The correlations
between key-worker and home-carer ratings were
highly significant for the MOAS (r = 0.486, P < 0.001),
less so for the ABC-I (r = 0.243, P < 0.01) and just not
significant for the ABC-H (r = 0.176, P = 0.059).
All three key-worker ratings of challenging behaviour
were significantly correlated with their ratings on the
Controllability Beliefs Scale (ABC-H: r = 0.173, P < 0.02;
ABC-I: r = 0.188, P < 0.02; MOAS: r = 0.148, P < 0.05),
indicating that service users who were seen as more
able to control their challenging behaviour were rated as
more challenging. Key-workers CBS ratings were not
significantly related to age (r = 0.044), IQ (r = 0.133) or
gender (t = 1.1). Key-workers ratings of challenging
behaviour were also unrelated to IQ (r = 0.04 on all
three measures).
Regression analyses
The regression analyses for the three sets of PI ratings
are summarized in Table 1, with the significant
predictors that are discussed below highlighted. The
upper part of the table shows the estimated effect size
and P-value for each of the individual variables; the
lower part of the table shows the goodness of fit for
each overall model, the proportion of variance (raw and
adjusted R2) accounted for by each block of data and
the change in R2 attributable to each block of data, with
the associated P-value.
For service users, demographic variables were a
marginally significant predictor of PI ratings (block 1:
P = 0.047), and the model improved very significantly
when mental health variables were added (block 2:
2013 John Wiley & Sons Ltd, 26, 410419
Journal of Applied Research in Intellectual Disabilities 413
P < 0.001); adding challenging behaviour variables (block
3) did not significantly improve the model. The significant
predictors were age (older service users rated themselves
as less angry) and anxiety. As anxiety was highly
correlated with depression, the latter is interpreted as a
proxy for poor mental health.
For both key-workers and home carers, IQ was a
significant predictor of their PI ratings, with more able
service users rated as more angry. For key-workers, the
addition of mental health variables significantly
improved the model (block 2: P = 0.012), reflecting a
significant effect of depression (P = 0.007), which was
also almost significant in the home-carer model
(P = 0.053). However, for both sets of carers, the effect of
depression disappeared when challenging behaviour
was added to the model (block 3: P < 0.001), with
significant prediction of PI by ABC-I scores (key-
workers) and MOAS scores (home carers). Again, given
the high intercorrelations between challenging behaviour
measures, these results are interpreted to mean that
challenging behaviour was a more important predictor
of PI ratings for both sets of carers than their perceptions
of the service users mental health. The significant effect
of GDS score in block 2 but not in block 3 of the key-
worker model probably reflects the fact that these ratings
were significantly correlated with key-worker ABC-I
scores (r = 0.348, P < 0.001).
A further predictor in the home-carer model was age,
which was significant in all three stages of the analysis:
older service users were rated as less angry, consistent
with service users self-ratings. However, there was no
hint of this relationship in key-worker ratings, where
the first-order correlation between age and PI was close
to zero (r = 0.01).
The outcomes of these analyses are summarized in
Figure 1. Older service users were rated as less angry
by service users and home carers but not by key-
workers; more intellectually able service users were
rated as more angry by both sets of carers but not by
the service users themselves; and, as predicted, mental
health status (but not challenging behaviour) predicted
service users self-ratings of anger, whereas challenging
behaviour (but not mental health) predicted carers
ratings of service users anger.
Discussion
The participants in this study were not a random
sample of people with intellectual disabilities. They
were recruited to a controlled trial of anger
management on the basis that they were considered by
414 Journal of Applied Research in Intellectual Disabilities

Table 1 Predictors of provocation index (PI) score at baseline

Service-user model Key-worker model Home-carer model

(n = 163) (n = 162) (n = 114)

Block Variable Beta P-value Beta P-value Beta P-value

1: Demographics Age of SU 0.17 0.029 0.00 0.963 0.19 0.034

Age of KW 0.08 0.309
Age of HC 0.21 0.022
Gender of SU 0.11 0.169 0.02 0.795 0.06 0.537
Gender of KW 0.11 0.185
Gender of HC 0.01 0.910
Full Scale IQ 0.07 0.343 0.21 0.010 0.28 0.003
2: Demographics and mental health scores Age of SU 0.16 0.033 0.01 0.920 0.24 0.010
Age of KW 0.09 0.233
Age of HC 0.17 0.069
Gender of SU 0.15 0.052 0.04 0.589 0.04 0.698
Gender of KW 0.14 0.095
Gender of HC 0.07 0.440
Full Scale IQ 0.05 0.494 0.19 0.014 0.27 0.004
GDS 0.12 0.257 0.30 0.007 0.24 0.053
GAS 0.24 0.020 0.08 0.479 0.03 0.812
RSES 0.00 0.987 0.01 0.945 0.04 0.654
3: Demographics, mental health Age of SU 0.18 0.027 0.05 0.556 0.21 0.015
and challenging behaviour scores Age of KW 0.01 0.911
Age of HC 0.07 0.475
Gender of SU 0.16 0.052 0.08 0.320 0.06 0.499
Gender of KW 0.16 0.052
Gender of HC 0.17 0.085
Full Scale IQ 0.05 0.506 0.23 0.003 0.26 0.004
GDS 0.11 0.318 0.13 0.244 0.17 0.135
GAS 0.25 0.019 0.07 0.473 0.02 0.858
RSES 0.01 0.913 0.01 0.945 0.07 0.404
ABC-H (KW) 0.09 0.401 0.04 0.721
ABC-H (HC) 0.07 0.587
ABC-I (KW) 0.04 0.759 0.26 0.044
ABC-I (HC) 0.15 0.288
MOAS (KW) 0.03 0.761 0.10 0.334
MOAS (HC) 0.27 0.044

Summary of PI models: goodness of fit measures

Model F df P (model) R2 Adjusted R2 R2 Change P (change)

Block 1 (SU) 2.71 3,162 0.047 0.049 0.031 0.049 0.047

Block 2 (SU) 5.03 6,162 <0.001 0.162 0.130 0.113 <0.001
Block 3 (SU) 3.39 9,162 0.001 0.166 0.117 0.004 0.851
Block 1 (KW) 1.98 5,161 0.084 0.060 0.030 0.060 0.084
Block 2 (KW) 2.72 8,161 0.008 0.125 0.079 0.065 0.012
Block 3 (KW) 3.74 11,161 <0.001 0.215 0.158 0.091 0.001
Block 1 (HC) 4.52 5,113 0.001 0.173 0.135 0.173 0.001
Block 2 (HC) 3.85 8,113 0.001 0.227 0.168 0.054 0.069
Block 3 (HC) 5.61 11,113 <0.001 0.377 0.310 0.150 <0.001

Significant beta and P-values (<0.05) are bold-faced.

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 Journal of Applied Research in Intellectual Disabilities 415

GDS .70
Mental GAS: P < 0.02
health GAS Service user
.38 MH: P < 0.001 PI
measures
.30
RSES

P < 0.05

ABC-H .64

ABC-I ABC-I: P < 0.05 Age of

Key-worker .45 Key-worker PI
CB: P < 0.001 service user
.63 P < 0.01
MOAS
Challenging FSIQ of
behaviour service user P < 0.02
measures .71
ABC-I P < 0.01
MOAS: P < 0.05
.69 MOAS Home carer PI
Home carer CB: P < 0.001

ABC-H .51

Figure 1 Predictors of PI scores. Within the circles are shown the intercorrelations between measures of mental health (MH: above)
and challenging behaviour (CB: below). The arrows to the right of the circles show the individual measures (above the arrow) and
blocks of data (below the arrow) that significantly predict PI scores. Other significant predictors (age and IQ) are shown to the right.

their service to display problem levels of anger. Not
surprisingly, given the well-described relationship
between anger and challenging behaviour among people
with intellectual disabilities (Taylor et al. 2005; Benson &
Brooks 2008; Rose et al. 2008), high levels of challenging
behaviour were also reported for some participants.
There is a limit to the extent of challenging behaviour
that could in principle be observed in this study
because most of the services from which participants
were recruited would often exclude individuals who are
overtly challenging. Nevertheless, 26% of participants
met the criterion for severe challenging behaviour.
While this is not a high proportion of the sample, the
proportion among the general population supported by
the participating services would be lower. Mean ABC
scores were about 30% higher than those reported in an
unselected sample of individuals attending comparable
services (Rose & Gerson 2009). Using the same criterion,
rates of severe challenging behaviour have been reported
to be 15% in the general population of people with
intellectual disabilities (Felce et al. 2009) and 22% in
residential services (Felce et al. 2011). These figures
include individuals with severe and profound disabilities
and people who challenge at a level that cannot be
managed within many services providing day activities.
Neither of these groups would have been eligible for the
present study. Because this was a relatively challenging
sample, who had been identified as having problems
with anger control, it is uncertain whether the present
results would generalize to service users with fewer
anger issues.
In addition to challenging behaviour, the participants
also reported very high levels of psychopathology.
Population estimates of the prevalence of depression and
anxiety among people with intellectual disabilities are,
respectively, <4 and 510% (Eaton & Menolascino 1982;
Borthwick-Duffy 1994a; Deb et al. 2001). However, among
the present participants, 34 and 73% met the Glasgow
Scale criteria for diagnoses of depression and anxiety,
respectively. The association between problem anger and
high levels of psychopathology is consistent with
previous reports in people with intellectual disabilities
(e.g. Moss et al. 2000) and in the general population (e.g.
Hull et al. 2003; Novaco 2003; Ghazinour & Richter 2009).
For all three sets of respondents, significant predictors
of PI scores were identified, which included both
demographic (age, IQ) and clinical variables. The
regression models account for a relatively small
proportion of the overall variance (1231%), but this is
not surprising, considering that the models did not

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416 Journal of Applied Research in Intellectual Disabilities
include any variables directly related to the service
users personal history or environment.
To the best of our knowledge, this is the first study to
report age-related changes in anger in people with
intellectual disabilities. However, the decline in anger
with age is consistent with the literature on challenging
behaviour, which is known to increase during child-
hood, with a peak in young adulthood and a subsequent
decline (Borthwick-Duffy 1994b; Holden & Gitlesen
2006). There are several reports in the general population
that adults experience anger less frequently and intensely
with increasing age (Gross et al. 1997; McConatha et al.
1997; Phillips et al. 2006; Schieman 1999; Schieman
2010), express anger less destructively (Thomas 1995,
2002; Tangney et al. 1996) and are less prone to attribute
anger to others (Riediger et al. 2011). The decrease in
anger with age reported by service users and their home
carers is consistent with these studies and extends the
obsevation of decreasing anger with age to people with
intellectual disabilities. However, while the age-related
decline in anger was reported by the service users
themselves and their home carers, it was not reported by
their key-workers. We have no explanation for this
difference.
Both sets of carers rated more able participants as more
angry. We are not aware of any previous studies of the
prevalence of anger in relation to IQ. There have been a
number of studies of aggressive challenging behaviour in
relation to IQ, but these are inconsistent: they include
reports of an increase (Borthwick-Duffy 1994b; Crocker
et al. 2006; Tyrer et al. 2006), no change (McClintock et al.
2003; Lowe et al. 2007; Felce & Kerr 2012) or a decrease
(Holden & Gitlesen 2006) in aggression as the degree of
intellectual impairment increases. (We did not observe
any relationship between challenging behaviour and IQ,
perhaps because the IQ range was narrower than in
previous studies, which, unlike the present study, also
included people with severe and profound disabilities.)
One potential explanation of the positive relationship
between anger and IQ is that staff may consider more
able service users to have more effective control over
their aggressive behaviour, which, for example, would
enable more intellectually able service users to express
their anger in more sophisticated ways, such as planned
aggression or acts of revenge. A relationship between
control and IQ is suggested by the finding of Tynan &
Allen (2002) that staff judged individuals with mild
disabilities to be more in control of their physically
aggressive behaviour than individuals with severe
disabilities who displayed similar behaviour. Indeed, we
did find small correlations indicating that service users
who were rated as more in control of their behaviour were
also rated as somewhat more challenging. A similarly
sized correlation (albeit non-significant because the
sample was smaller) was reported by Mills & Rose (2011).
However, while there was a small correlation between
key-worker ratings of controllability and severity of
challenging behaviour, we found no relationship between
controllability ratings and IQ, consistent with earlier
studies (MacKinlay & Langdon 2009; Dilworth et al.
2011). Therefore, increased control cannot explain why
more able service users were rated as more angry.
Alternatively, the relationship between anger and IQ
could be artefactual. Some of the items on the PI refer to
relatively subtle social threats that carers may feel would
not be understood by less able service users (e.g. being
charged too much money for getting something fixed):
other things being equal, low scores on these particular
items would lead to less able service users receiving a
lower overall score.
The most important finding of this study was that, as
predicted from earlier data (Rose et al. 2000; Rose &
Gerson 2009), service users and carers use different
constructs when rating the service users anger. Service
users rate their behaviour on the basis of their internal
emotional state and mental health, as reflected by their
ratings of anxiety and depression, whereas carers (both
key-workers and home carers) rate service users anger
on the basis of overt behaviours, as measured by the
challenging behaviour scales. As previously reported
(Rose & Gerson 2009), there was a very low correlation
between service-user and carer anger ratings, which in
this study accounted for <3% of the variance. This is not
surprising considering that the two ratings are based on
differing sets of variables and perceptions.
These results have implications for the assessment
of psychological well-being and the outcome of
psychological interventions for people with intellectual
disabilities. While staff are able to rate important
changes in the lives of people with intellectual
disabilities, they clearly do not have direct access to
their subjective experiences. The present results support
the importance of trying to access the personal
experiences of people with intellectual disabilities as the
most crucial element in the evaluation of an individuals
well-being, as it is clear that carers are only able to
assess a small part of the information being used by the
clients with whom they are working. The differences
between the two sets of carers also suggest that some of
the elements used by carers to rate an individual may
vary between both environments and individuals, or
perhaps some service users behave in different ways
2013 John Wiley & Sons Ltd, 26, 410419

across settings (cf. Willner et al. 2005). This again
underlines the importance of placing individuals at the
centre of their own assessment and using carers to
triangulate aspects of the assessment.
Interestingly, in the study of Rose & Gerson (2009),
service-user and carer anger ratings became highly
correlated (r = 0.61) after the service-user and carer had
attended an anger management course together. On
similar lines, staff supporting service users attending
individual cognitive-behavioural therapy sessions made
little mention of service users inner lives or well-being
when interviewed about their expectations of therapy,
but showed more awareness of these issues when
interviewed after the therapy (Stenfert Kroese et al. 2013).
These findings suggest that carers can become more
attuned to the service users subjective experiences, but
this needs some work: it does not come naturally.
Acknowledgments
This project was funded by the NIHR Health Technology
Assessment programme and will be published in full in
the Health Technology Assessment journal series. Visit
the HTA programme website www.hta.ac.uk/ for more
details and for the link to project page. The views and
opinions expressed therein are those of the authors and
do not necessarily reflect those of the Department of
Health. The present authors also acknowledge the
support provided to SEWTU by the National Institute for
Social Care and Health Research Clinical Research Centre
(NISCHR CRC).
Correspondence
Any correspondence should be directed to Professor Paul
Willner, Psychology Dept, Swansea University, Singleton
Park, Swansea SA2 8PP, UK (e-mail: p.willner@swansea.
ac.uk).
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