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Archives of Psychiatric Nursing

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The Effects of Anger Management Education on Adolescents' Manner ofDisplaying Anger and Self-Esteem: A Randomized Controlled Trial

Neslihan Löka, Kerime Bademlib,⁎, Muammer Canbazc

a Selçuk University, Faculty of Health Science, Turkeyb Akdeniz University, Faculty of Nursing, Turkeyc Selçuklu Anatolian School, Turkey

Introduction

Adolescence, one of the key stages of development, is a period whenmany fundamental physical and psychological changes occur.Adolescents must cope with a higher number of the biopsychosocialchanges compared to children. They may have difficulties in managingtheir emotions and behavior because they still do not have sufficientlevels effective coping experience (Blakemore & Mills, 2014; Holder &Blaustein, 2014). One of the keys to a trouble-free adolescence is torecognize the emotions intensely felt during this period and to controlthe behaviors displayed because of these emotions (Kidwell, Van Dyk,Guenther, & Nelson, 2016). Anger is one of the common feelings withpotentially destructive consequences experienced by everyone at onetime or another in daily life (Berkowitz & Harmon-Jones, 2004). Angeris a constructive force when it is used to solve problems, correct aninjustice or a mistake, or restore self-esteem and pride. Although angeris a natural, healthy, appropriate, life-enhancing emotion, it none-theless may be destructive to a child's psychological and physical well-being if not appropriately managed (Ayebami & Janet, 2017; Modrcin-McCarthy, Pullen, Barnes, & Alpert, 1998).

Anger is an important emotion expressed by adolescents as it is in allage groups, and so is the way they express their anger. Anger and theway it is expressed represent a major public health problem for ado-lescents today. It may cause physical, psychological, and social pro-blems for adolescents if not expressed in an appropriate manner(Starner & Peters, 2004). Prevalence reports show that anger-relatedproblems, such as oppositional behavior, verbal and physical aggres-sion, and violence, are some of the more common reasons children arereferred for mental health services (Blake & Hamrin, 2007). If adoles-cents do not learn how to manage their anger, future problems areinevitable for them. Anger can be destructive if it rages out of controland can cause problems in school, social life, personal relationships andthe overall quality of one's life (Cui, Morris, Criss, Houltberg, & Silk,2014; Down, Willner, Watts, & Griffiths, 2011; Hoogsteder et al., 2015;Shahbazi et al., 2017).People may feel compelled to move away whenanger is not expressed in an appropriate manner. This may make theangry person have a negative self-perceptions and a low level of self-

esteem, and feel guilty (Albayrak & Kutlu, 2009; Edwards, 2013;Özmen, Özmen, Çetinkaya, & Akil, 2016).

When adolescents become able to cope with the controversial andproblematic situations, their self-perception improves and matures.Anger affects self-perception because it is displayed in a situation whereindividuals are restrained or challenged. An adolescent's reaction to-ward anger is largely related to his/her personal characteristics, ex-periences, and expectations from previous experiences, and thus, to theconcept of self-perception. Meta-analyses have found that adolescents'anger is related to constant anxiety, depression, stress, exposure toviolence, hostility, low self-esteem, and insufficient social support(Mahon, Yarcheski, Yarcheski, & Hanks, 2010). Anger enables people tomaintain the borders of self-perception and self-esteem, and to advocatefor themselves (Kernis, Grannemann, & Barclay, 1989; Papps &O'Carroll, 1998). Self-esteem reflects individuals' positive and negativeattitudes about themselves. It can be defined as an individual's per-ception of his or her own worth (Rosenberg, Schooler, Schoenbach, &Rosenberg, 1995).

When people see their rights are violated, receive threats, or face anunbearable accusation, anger enables them to feel right or approved,and ensures them to maintain their self-esteem (Arslan, 2009). A studythat examined the relationship between the psychosocial variances andanger in adolescents found a positive relationship between anger andnegative experiences, anxiety, drug use, depressive symptoms (Puskar,Ren, Bernardo, Haley, & Stark, 2008). However, it showed that opti-mism had a negative relationship with the family support perceived bythe adolescent and their self-esteem (Puskar et al., 2008).

Adolescence is a period when people search for their identities.Therefore, self-perception gains importance during this period. Self-perceptions closely related to how people regard themselves: who theyare, and how they think and feel about themselves. A person may feeleither esteemed or worthless because of his/her self-perception.D'zurilla, Chang, and Sanna (2003) reported that low self-esteem wasrelated to anger and hostility. Adolescents with a low level of self-es-teem may have mental problems, including anxiety and depression(Klemanski, Curtiss, McLaughlin, & Nolen-Hoeksema, 2016; Orth,Robins, & Roberts, 2008).

https://doi.org/10.1016/j.apnu.2017.10.010Received 1 May 2017; Received in revised form 5 September 2017; Accepted 12 October 2017

⁎ Corresponding author at: Akdeniz University, Faculty of Nursing, 07050 Antalya, Turkey.E-mail address: [email protected] (K. Bademli).

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Numerous behavioral intervention programs have been developedto help adolescents cope with anger. Anger management interventionsaim to develop an awareness of the types, functions and meaning ofanger, its physical and psychological effects, and its expression(Deffenbacher, Oetting, & DiGiuseppe, 2002; Feindler & Engel, 2011;Yılmaz & Ersever, 2015). The meta-analysis conducted by Candelaria,Fedewa, and Ahn (2012) indicated that anger management interven-tions teach coping-skills to adolescents, and that emotional awareness,relaxation techniques, problem-solving cognitive-behavioral ap-proaches, and coping skill training are successfully used in these in-tervention. Commonly used therapeutic techniques for managing angerinclude affective education, relaxation training, cognitive restructuring,problem-solving skills, social skills training, and conflict resolution.These techniques, adapted to the needs of the adolescent, can fosteranger management and adolescents' psychological and physical well-being (Blake & Hamrin, 2007).

Maintaining and enhancing health is a fundamental part of nursingcare. Nurse practitioners working with adolescents who show theabove-mentioned symptoms should consider anger as a possible pre-cursor of the symptomatology (Mahon et al., 2010). Mental healthnurses can play a pivotal role in fostering change in the social climate ofschools and helping youth to achieve better anger management(Thomas & Smith, 2004). Psychiatric-mental health nurses are re-sponsible for identifying at-risk adolescent during health assessment.They are well-qualified to provide this psychoeducational intervention(Thomas, 2001). Furthermore, as part of their health promotion andhealth education practices in schools or community, psychiatric-mentalhealth nurses and primary care nursing specialists can easily teachadaptive coping skills to adolescents to regulate their anger (Puskar,Ren, & McFadden, 2015). Teaching adolescents the adaptive copingskills for anger is an important nursing intervention.

Schools are the most appropriate places where adolescents can re-cognize their anger and learn how to display this feeling in the bestpossible way. Therefore, comprehensive curricula are needed to teachadolescents how to properly recognize and display their emotions(Adana & Arslantaş, 2011).Practices related to the anger managementprogram within the nursing department of schools can be carried outunder the leadership and supervision of the psychiatric mental healthnurse. Considering the anger-related issues and the number of Turkishadolescents who have anger problems, it is clear that an easily applic-able and effective anger management program should be implemented.The improved anger management program aims to help students be-come competent in anger management. Systematic, planned and con-tinuous anger management programs have yet to be implemented inTurkey to improve the adolescents' ability to cope with anger. Thisstudy aims to develop and implement an effective anger managementprogram, to examine the effects of this program on senior students'manner of expressing their anger and self-esteem and the relationshipbetween them, and to popularize this program in schools.

Study aims and hypotheses

This study aims to examine the effects of anger management edu-cation provided to adolescents on the manner they display their angerand self-esteem.

Hypothesis 1a. The intervention and control groups will obtainsignificantly different mean scores on the anger symptomssubdimension of the multi-dimensional anger scale.

Hypothesis 1b. The intervention and control groups will obtainsignificantly different mean scores on the situations causing angersubdimension of the multi-dimensional anger scale.

Hypothesis 1c. The intervention and control groups will obtainsignificantly different mean scores on the anger-related ideassubdimension of the multi-dimensional anger scale.

Hypothesis 1d. The intervention and control groups will obtainsignificantly different mean scores on the anger-related behaviorssubdimension of the multi-dimensional anger scale.

Hypothesis 1e. The intervention and control groups will obtainsignificantly different mean scores on the interpersonal angersubdimension of the multi-dimensional anger scale.

Hypothesis 2. The intervention and control groups will obtainsignificantly different mean scores on the Rosenberg Self-Esteem Scale.

Methods

Design and Sample of Study

This experimental pretest-posttest study was designed as a singleblind, randomized controlled trial. It was conducted in a secondaryschool in Kepez county of Antalya, Turkey. The study population con-sisted of all final-year students in this school. Sample size calculationsrevealed that 56 participants were required to significantly test effectssized d = 0.78, when the alpha- and beta-error margins were acceptedto be lower than 0.05 and0.2, respectively. Accordingly, the studysample consisted of 60 students: 30 in the experimental group and 30 inthe control group. The inclusion criteria were being voluntary to par-ticipate, obtaining parents' approval, obtaining specified scores on themulti-dimensional anger scale (35 points from the first section, 105from the second, 75 from the third, 115 from the fourth, and 65 fromthe fifth), having low or medium levels of self-esteem according to theRosenberg self-esteem scale, and participating in all sessions. The ex-clusion criteria were any emotional disabilities and failure to partici-pate in two or more than two sessions. Independent variables of thestudy were anger management education and sociodemographic char-acteristics, and the dependent variables included the manner of dis-playing anger and the level of solving interpersonal problems.

Measurements

The data were collected using a students' sociodemographic in-formation form, the Multi-Dimensional Anger Scale (MDAS), and theRosenberg Self-Esteem Scale.

Multi-Dimensional Anger Scale (MDAS)

The Multi-Dimensional Anger Scale aims to determine anger-relatedemotions, ideas, and behaviors. It consists of five sections with Likerttype items which are scored between 1 and 5, corresponding to theanswers of “never”, “seldom”, “occasionally”, “frequently”, and “al-ways”. High scores indicate that the relevant dimension is considered orused frequently. The scale was developed by Balkaya and Sahin (2003)at the end of pilot studies, and its sections are: the First Section, “Anger-Related Symptoms” (14 items) (r = 0.84); the Second Section, “Situa-tions Causing Anger” (41 items) (r = 0.83); the Third Section, “Anger-Related Ideas” (30 items) (r = 0.68); the Fourth Section, “Anger-Re-lated Behaviors” (47 items) (r = 0.68); and the Fifth Section, “Inter-personal Anger” (26 items) (r = 0.64) [15]. In this study, the Cronba-ch's alpha values of these five sections were found to be r = 0.79,r = 0.83, r = 0.73, r = 0.86, and r = 0.72, respectively.

Rosenberg Self-Esteem Scale

This scale, used to measure self-esteem of particularly adolescents,was developed by Morris Rosenberg in 1963. It has been used in manystudies after reliability and validity study was conducted for this scalein the United States of America. The Turkish validity and reliabilitystudy of the scale was conducted by Çuhadaroğlu; who found the va-lidity coefficient to be r = 0.71 and the reliability coefficient to be

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r = 0.75, using the test-retest reliability method. The Rosenberg Self-Esteem Scale consists of 63 items in 11 subscales including self-esteem,sustainability of the term “self”, trusting people, sensitivity to criticism,depressive affection, imagining, perceiving threat in interpersonal re-lation, level of participating in discussions, psychic isolation, psycho-somatic symptoms, and parental care. The self-esteem subscale includesten items with positive and negative answers: items 1, 2, 4, 6, and 7question the positive self-evaluation, and items 3, 5, 8, 9 and 10questions the negative self-evaluation. The scores of 0 to 1 indicatehigh, 2 to 4 indicate medium, and 5 to 6 indicate low levels of self-esteem. Higher scores indicate low levels of self-esteem. Cronbach'salpha was found to be r = 0.73 for this scale in the present study.

Randomization

All students were evaluated based on the inclusion and exclusioncriteria. Blinding was not used in this study since a single researchercollected the pretest and posttest data and conducted the “AngerControl Training”. Fig. 2 shows the “Consort Scheme” of the study. Theparticipants were assigned to the intervention or control group usingthe simple randomization method. This process was performed usingthe following web page:http://www.randomizer.org/form.htm. Fig. 1illustrates the randomization process in the study.

Intervention

Anger management education was prepared based on the literature(Adana & Arslantaş, 2011; Arslan, 2009; Candelaria et al., 2012;Feindler & Engel, 2011; Starner & Peters, 2004; Sukhodolsky, Smith,McCauley, Ibrahim, & Piasecka, 2016). It was organized considering theeducational status of students and consisted of six sessions (Table 1).The first, second and sixth sessions of the education lasted for 45 min onaverage. The third, fourth and fifth sessions, which focused on im-proving the participants' coping skills, lasted for 60 min. The inter-vention group to whom the education was provided included fivegroups, with six participants in each group. Ten-minute breaks weretaken between the education sessions administered to each group. Theweekly education sessions of all groups were completed in one day. Nointervention was planned for the control group. The intervention groupdid not interact with the control group during the activities. The stu-dents in the experiment and control groups were not randomly dis-tributed and therefore not in the same class. The two groups were not

aware of each other when the anger control program was practicedwhen the students were idle. For this reason, they were not affected byeach other.

Data Collection

The pre- and post-test data were collected by the researchers fromthe voluntary student who have permission of their parents to partici-pate in the study in a classroom.

Statistical Analysis

Statistical analysis was performed using the SPSS 18.0 (IBM,Armonk, USA). Continuous data were presented as median (interquartile range), while categorical data were shown as counts and per-centages. The researchers used descriptive statistics including numbers,percentages, means and standard deviation. The Mann Whitney U testwas used to compare the pretest-posttest mean scores of the interven-tion and control groups. The Wilcoxon signed rank test was used toassess the pretest and posttest data of the intervention and controlgroups within themselves. The procedure described by Benjamini andHochberg was used to correct p-values for multiple testing.

Ethical Procedures

Ethical approval was obtained from the Ethics Committee ofAntalya Training and Research Hospital. An approval was also obtainedfrom the school administration. All participants were informed aboutthe title, duration and procedure of the study, and were asked to readthe consent form. Thereby, they were assisted to understand the pur-pose and scope of the study. A written informed consent was obtainedfrom each participant. Data collection process and intervention beganafter obtaining the participants' consent. All details about the inter-vention were explained to the intervention group.

Results

No statistically significant difference was found between the socio-demographic characteristics of the experimental and control groups(p > 0.05).

Fig. 1. Determination of the randomization.

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Findings of the Adolescents' Self-Esteem Levels

Self-esteem levels of the adolescents in the experimental group werefound to significantly increase after the program (p < 0.05). No sig-nificant difference was found in the self-esteem levels of the adolescentsin the control group before and after the program (p > 0.05). Nodifference was found between the self-esteem levels of the experimentaland control groups during the pre-test measurements (p > 0.05);however, a significant difference was found during the post-test mea-surements (p < 0.05) (Table 2).

Findings of the Adolescents' Anger Levels

The Multi-Dimensional Anger Scale was administered before andafter anger management education, and the difference between anger

Fig. 2. Consort.

Table 1Anger management education.

Sessions Session objectives

Session 1: Meeting Objective: Giving details about anger management education(Objectives: Providing information on the details of the program,explaining the rules, and administering a pre-test)

Session 2: Recognizing anger Objective: Recognizing the reasons and symptoms for anger(Objectives: Acquiring the ability to describe personal feelings, feelings of anger, the reasons behind the anger, andthe physical and emotional symptoms of anger)

Session 3: Controlling anger – breathing and relaxingexercises

Objective: Learning how to control and cope with anger (developing physical coping skills)(Objectives: Knowing the methods of coping with stress and acquiring the ability to apply at least one of them)

Session 4: Controllıng anger – (changing mind, solvingproblems)

Objective: Learning how to control and cope with anger (developing emotional and ideal coping skills)(Objectives: Acquiring the ability to define the situations that cause anger and to cope with anger, and performinga case study)

Session 5: Controlling anger – (moving away from the place,letting off steam)

Objective: Learning how to control and cope with anger (developing emotional and ideal coping skills)(Objectives: Acquiring the ability to define the situations that cause anger and to cope with anger, and performinga case study, coping)

Session 6: General evaluatıon Objective: Evaluating the anger management program(Objective: General evaluation, recommendations and ending)

Table 2Comparing the pre- and post-test results related to self-esteem of the adolescents.

RBSO Experimental group(n:30)Median (%25–%75)

Control group(n:30)Median (%25–%75)

U p

Baseline 2.30 (1.50–3.80) 2.20 (1.40–3.70) 43.500 0.75Post intervention 4.60 (3.30–5.90) 2.30 (1.60–3.90) 11.700 0.001Z value 0.260 5.399p p < 0.001 0.795

Z = Wilcoxon Analysis, d.f. (“degree of freedom”):2, U = Mann Whitney U.

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levels was examined (Table 3).

Anger-related Symptoms

The scores experimental group on the anger-related symptomssubdimension was found to significantly reduce after the program(p < 0.05). On the other hand, the scores of the control group did notsignificantly change after the program (p > 0.05). No significant dif-ference was found between the pre-test mean scores of the experimentaland control groups on the anger-related symptoms subdimension(p > 0.05). However, a significant difference was found between theirpost-test mean scores (p < 0.05) (Table 3).

Situations Causing Anger

The scores experimental group on the situations causing angersubdimension was found to significantly reduce after the program(p < 0.05). On the other hand, the scores of the control group did notsignificantly change after the program (p > 0.05). No significant dif-ference was found between the pre-test mean scores of the experimentaland control groups on the situations causing anger subdimension(p > 0.05). However, a significant difference was found between theirpost-test mean scores (p < 0.05) (Table 3).

Anger-related Ideas

The scores experimental group on the anger-related ideas sub-dimension was found to significantly reduce after the program(p < 0.05). On the other hand, the scores of the control group did notsignificantly change after the program (p > 0.05). No significant dif-ference was found between the pre-test mean scores of the experimentaland control groups on the anger-related ideas subdimension(p > 0.05). However, a significant difference was found between theirpost-test mean scores (p < 0.05) (Table 3).

Interpersonal Reactions Toward Anger

The scores experimental group on the interpersonal reactions to-ward anger subdimension was found to significantly reduce after theprogram (p < 0.05). On the other hand, the scores of the control groupdid not significantly change after the program (p > 0.05). No sig-nificant difference was found between the pre-test mean scores of theexperimental and control groups on the interpersonal reactions towardanger subdimension (p > 0.05). However, a significant difference wasfound between their post-test mean scores (p < 0.05) (Table 3).

Anger-related Behaviors

The scores experimental group on the anger-related behaviors sub-dimension was found to significantly reduce after the program(p < 0.05). On the other hand, the scores of the control group did notsignificantly change after the program (p > 0.05). No significant dif-ference was found between the pre-test mean scores of the experimentaland control groups on the anger-related behaviors subdimension(p > 0.05). However, a significant difference was found between theirpost-test mean scores (p < 0.05) (Table 3).

Discussion

This study showed that anger management education positivelyaffected adolescents' manner of displaying anger and self-esteem. Asignificant reduction was seen in the adolescents' anger that arise due tobeing neglected, facing injustice, and being negatively criticized.Adolescence is a sensitive period during which biopsychosocial changesoccur (Suldo, Shaunessy, & Hardesty, 2008).This means that bothphysical changes, such as the changes in height and body weight, theskeletal development and the hormonal changes, and psychosocialchanges are observed in this period. These changes can engender manyproblems. The stress caused by the rapid development and changes,combined with a lack of knowledge and experience, makes it difficult

Table 3Comparing the pre- and post-test results related to anger levels of the adolescents.

Multi-Dimensional Anger Scale (MDAS) Experimental group(n:40)Median (%25–%75)

Control group(n:40)Median (%25–%75)

Ua p

Anger-related symptomsBaseline 50.60 (43.00–57.50) 48.00 (42.00–51.00) 33.500 0.23Post intervention 33.50 (22.00–44.50) 47.00 (44.50–49.00) 94.500 0.003Z valuea 0.959 1.656p p < 0.001 0.10

Situations causing angerBaseline 153.00(145.00–161.00) 146.50 (122.00–170.00) 41.700 0.98Post intervention 123.50 (115.50–131.50) 52.00 (43.50–55.50) 85.750 0.012Z valuea 0.706 9.603p p < 0.001 0.38

Anger-related ideasBaseline 120.00 (105.50–135.50) 118.50 (108.50–128.50) 448.500 0.28Post intervention 100.00 (84.50–115.50) 120.00 (110.00–130.50) 417.00 0.017Z valuea 0.654 2.552p p < 0.001 0.80

Interpersonal reactions toward angerBaseline 160.00 (140.50–180.50) 37.00 (29.50–39.50) 563.500 0.22Post intervention 135.00 (105.50–165.50) 35.00 (29.50–37.50) 82.500 0.024Z valuea 3.426 4.349p 0.01 0.42

Anger-related behaviorsBaseline 186.00 (166.50–206.50) 179.00 (166.50–192.50) 156.500 0.42Post intervention 142.00 (122.50–162.50) 176.00 (167.00–185.50) 683.500 0.028Z valuea 5.231 9.467p 0.02 0.53

a Z = Wilcoxon Analysis, d.f. (“degree of freedom”):2, U = Mann Whitney U.

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for adolescents to comply with the governing social order and rules.This situation may create certain problematic issues, such as seeking forautonomy, conflicts with parents, and defiance to comply with the so-cial environment. In effect, these issues and others like them may makeadolescents more vulnerable, angry and even aggressive (Mahon et al.,2010; Musante & Treiber, 2000). Although anger is a common andnatural feeling, or an internal event, problems associated with in-appropriate expression of anger is one of the most serious concerns ofparents, educators, and the mental health community (Feindler &Engel, 2011). Therefore, people should learn the methods of copingwith short temper and anger. A meta-analysis that examined the ef-fectiveness of anger management programs also reported that theseprograms were effective (Candelaria et al., 2012).

One of the expected results of the anger management education isthe positive changes in the emotions and behaviors displayed after anexperience that elicits anger. Since the recognition and management ofthe symptoms of anger are generally related to cognitive and behaviorallearning, treatment strategies should include a learning method(Flanagan, Allen, & Henry, 2010). Sessions of anger managementeducation developed in this study about the recognition and reasons ofanger, and the anger-related symptoms were effective in acquiringsufficient knowledge and skills to cope with the anger-related symp-toms.

The anger-related ideas subdimension of the multi-dimensionalanger scale examines the adolescents' anger-related ideas about them-selves, other people, and the world. The participants' negative anger-related ideas significantly reduced after the education. Anger is ex-pressed by actions or overt behaviors, but it also has a notable cognitivecomponent. Cognition should not be underestimated because it can playsignificant roles in the development of anger and its overt expression, aswell as anger control (Flanagan et al., 2010; Kerr & Schneider,2008).Cognitive processes occur when anger is expressed, as opposed tobeing managed. The anger management education raised the adoles-cents' awareness; and positive changes occurred in adolescents' cogni-tive processes related to anger. Studies on anger management havereported a change in the opinions about anger (Deffenbacher et al.,2002; Feindler & Engel, 2011; Yılmaz & Ersever, 2015). They haveparticularly indicated that the adolescents who attended the educationprograms on anger gained greater awareness of the type, function andmeaning of anger, acquired information about the physical and psy-chological effects and expression of anger, and became able to controltheir anger after the education (Deffenbacher et al., 2002; Feindler &Engel, 2011; Yılmaz & Ersever, 2015).

The participants' scores on the interpersonal anger subdimensions,including revenge reactions, passive and aggressive reactions, in-troverted reactions, and careless reactions, significantly reduced afterthe education. Thomas (2001) also reported that by gaining the abilityto control the anger, interpersonal relationships improved. In addition,significant reductions were observed in the scores of the participants onthe subdimensions about anger management education, anger-relatedaggressive behaviors, calm behaviors, and anxious behaviors. Psy-choeducational programs have been shown to lead to reductions in thesymptoms of anger, hostility, and depression, and to increased self-ef-ficacy for the management of behavioral problems (Glancy & Saini,2005). Previous studies have indicated that anger management pro-grams were effective in reducing students' aggressive behavior andanxiety levels and in increasing their level of anger control(Deffenbacher et al., 2002; Glancy & Saini, 2005; Sukhodolsky,Kassinove, & Gorman, 2004; Thomas, 2001). This may be attributed toadolescents' learning how to display and control their anger during theanger management education. Another study that analyzed the effec-tiveness of an anger control program similarly showed that the programreduced students' mean scores associated with anxiety, depression,aggressive behaviors, negative self-perception and hostility (Avci &Kelleci, 2016).Uncontrolled anger is a predictor of many psychiatricdisorders, and unexpressed, continuous and intense anger is

particularly known to have an important role in the development ofdepression and anxiety (Gresham, Melvin, & Gullone, 2016).

The present study showed a significant increase in the participants'self-esteem. A previous study reported that self-esteem was related toanger (Kernis et al., 1989). Another study indicated that anger wasrelated to adolescents' low self-esteem (D'zurilla et al., 2003). Finally, astudy showed that higher self-esteem led to a lower level of trait angerand a higher level of anger control (Arslan, 2009). Therefore, enhancingthe adolescents' self-esteem is an effective method of helping them copewith anger. This study indicated that the anger management educationenabled the control of anger and increased self-esteem levels.

Limitations

The limitation of this study is the participation of only the final-yearstudents of a secondary school in Kepez county of Antalya who wereopen to communication.

Conclusion

This study contributes to the existing literature by showing thebenefits of preventive interventions for adolescent offenders. The angermanagement education was found to reduce Turkish adolescents' angerand increase their self-esteem. The anger management program used inthis study was developed to provide primary and secondary preventionfor aggressive adolescents. Based on the results of this study, it is re-commended that group studies and events be organized in schools inorder to teach anger management skills. In addition, health promotionprograms conducted by psychiatric nurses can target the self-esteemsymptoms and promote anger management for adolescents.

Relevance for Community Mental Health

The anger management education provided to adolescents is effec-tive inhelping them both cope with anger and enhance their self-es-teem. Schools need to have comprehensive curricula to teach adoles-cents how to properly recognize and display their emotions. Practicesrelated to the anger management program can be carried out within theschool nursing departments under the leadership and supervision of thepsychiatric mental health nurse. Psychiatric mental health nurses canplay a key role in increasing awareness about anger, the interventionsavailable to address anger issues and the associated psychosocial fac-tors, which can be achieved through community education, early as-sessment and intervention, in collaboration with other healthcare pro-viders and school health officials.

Conflict of interest

No conflict of interest has been declared by the authors.

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