Stakeholder views on the barriers and facilitators of psychosocial interventions to address reduction in aggressive challenging behaviour in adults with intellectual disabilities

Background Success of psychosocial interventions in reducing aggressive challenging behaviour is likely to be related not only to mechanistic aspects but also to therapeutic and system factors. The study aims to examine the facilitators and barriers that influence whether psychosocial interventions for aggressive challenging behaviour in adults with intellectual disabilities lead to positive change. We conducted 42 semi-structured interviews with adults with intellectual disabilities who display aggressive challenging behaviour, family/paid carers, and professionals engaged in or delivering a psychosocial intervention across the UK. Data were analysed thematically using a framework approach. Stakeholders considered therapeutic and supportive relationships and personalised care as facilitating factors in addressing aggressive challenging behaviour. The operational structure of community intellectual disability services and conflicting expectations of professionals and carers were the main contextual barriers that impeded the implementation of psychosocial interventions in adults with intellectual disabilities. Findings highlight the valued components that maximise positive change in adults with intellectual disabilities who display aggressive challenging behaviour. Several operational adjustments including referral criteria, roles of professionals and workforce issues need to be addressed in services to maximise the implementation of psychosocial interventions leading to reduction in aggressive challenging behaviour in this population.


Introduction
Aggressive challenging behaviour is reported in 8% of adults with intellectual disabilities known to services (Bowring et al., 2017) with rates up to 53% for verbal aggression followed by 48% for physical aggression across settings (e.g., community group homes, residential settings) (O' Dwyer et al., 2018).Examples of aggressive challenging behaviour might include incidents of damage to property and/or antisocial behaviour (Deb et al., 2016).Aggressive challenging behaviour in adults with intellectual disabilities are often triggered by environmental factors including unexpected changes and/ or demands to the person as well as other factors such as medication, mental health conditions, and level of intellectual functioning (van den Bogaard et al., 2018).
Existing interventions for aggressive challenging behaviour in adults with intellectual disabilities living in the community include behavioural approaches such as Positive Behavioural Support (PBS) and/or Applied Behavioural Analysis (ABA), Cognitive Behaviour Therapy (CBT) informed anger management along with pharmacological (e.g., antipsychotic medication) and alternative approaches (e.g., art therapy, sensory integration) (NICE, 2015).Nonetheless, there is limited evidence for other psychosocial approaches which may be helpful to some adults with intellectual disabilities who display aggressive challenging behaviour such as Dialectical Behaviour Therapy (DBT) (Brown et al., 2013) and mindfulness (Singh et al., 2013;Singh et al., 2016;Singh et al., 2020).Psychosocial interventions aim to meet unmet needs of adults with intellectual disabilities including housing, self-care, social and interpersonal skills, daytime activities, and housekeeping for those in family, supported or residential care homes (Gustafsson et al., 2009).
Although, the evidence-base and benefits of psychosocial interventions for reducing aggressive challenging behaviour in adults with intellectual disabilities are undisputed (Browne & Smith, 2018; Vereenooghe & Langdon, 2013), it is accepted that not all adults with intellectual disabilities respond to them.In addition, there is scarce understanding of how those who receive these interventions experience them and what their expectations are.The presence of aggressive challenging behaviour impacts not only the well-being of the individual with intellectual disability who might or might not be able to communicate their needs (van den Bogaard et al., 2018), but also has consequences for the surrounding environment including family members and/or paid carers who might be recipients of aggressive incidents (van den Bogaard et al., 2018).
Research has explored the mechanisms that maximise engagement with psychosocial therapy for adults with intellectual disabilities.A qualitative study described the facilitators and barriers of positive therapeutic change (i.e., engagement in therapy, generalisation of acquired skills) following access to mental health services (Ramsden et al., 2016).Triads of six adults with mild intellectual disability who had accessed and benefited from the service, their (six) carers and three clinical psychologists working in the service agreed that a supportive network, a good therapeutic relationship, and adaptations in sessions facilitated positive therapeutic change, whereas communication and cognitive limitations as well as acceptance of the problematic behaviour impeded engagement in therapy (Ramsden et al., 2016).Other studies explored the views of multiple stakeholders about PBS implementation in different settings (i.e., inpatient mental health, forensic, community intellectual disability services) (Bosco et al., 2019;Clark et al., 2020;Karger et al., 2018).Professionals, carers (family or paid) and adults with mild intellectual disabilities described PBS as a beneficial approach to get to know the needs of individuals which in turn may promote holistic care (Bosco et al., 2019;Clark et al., 2020;Karger et al., 2018).However, professionals and care home managers emphasised that PBS plans were not only poorly implemented, but there was confusion about their purpose and use within the team (Clark et al., 2020).Barriers to PBS implementation included differences in staff attitudes towards and knowledge of PBS, resistance to change, organisational issues such as understaffing, and poor motivation and engagement of staff due to PBS being perceived as time consuming (Bosco et al., 2019;Clark et al., 2020;Karger et al., 2018).Overall, they all perceived PBS as leading to an improved collaborative and personalised approach to patient care and, therefore, were willing to adopt it in their effort to reduce restrictive practices (Bosco et al., 2019;Clark et al., 2020).
A recent review summarised the perceived facilitators and barriers to the use of Active Support in adults with intellectual disabilities in residential care (Flynn et al., 2018).Active Support can be described as a preventative intervention that aims to maximise opportunities for adults with intellectual disabilities to be active members in the community they live in, with supervision from care home staff members.However, evidence is inconclusive in relation to its effect on minimising challenging behaviours including aggression towards people and/or property among other behaviours (Stancliffe et al., 2008;Totsika et al., 2008).The review findings suggested that training residential care staff, supervision, and peer support facilitated the implementation of Active Support in residential care for adults with intellectual disabilities (Flynn et al., 2018).Whereas, operational issues including staff retention, lack of support and leadership followed by low levels of staff motivation and absence of knowledge on how to manage challenging behaviours impeded the implementation of Active Support uptake by staff working in residential care (Flynn et al., 2018).Interestingly, a meta-analytic review suggested that following staff training, the attitude of care home staff working with adults with intellectual disabilities who display aggressive challenging behaviour changed but staff training itself was not effective in reducing aggressive challenging behaviour in adults with intellectual disabilities (Knotter et al., 2018).
Overall, there is limited in depth understanding of the experience of care and the reasons that promote or impede the reduction of aggressive challenging behaviour in adults with intellectual disabilities.This qualitative study explored the experiences of triads of adults with mild/moderate intellectual disabilities with a history of aggressive challenging behaviour, their family and/or paid carers, and health and social care professionals involved in their care of previously received psychosocial interventions.The objective was to better understand what constitutes facilitators and barriers in achieving positive change defined as reduction in aggressive challenging behaviour.

Patient and Public Involvement
The study recruited two panels of experts by experience, one with adults with intellectual disabilities (n=4) and the other with family carers (n=5) to shape the methodology.Participants information sheets, consent forms and topic guides for each stakeholder group were developed with input from researchers and the two panels of experts by experience.The two panels guided the analytic approach and participated actively in the interpretation of qualitative findings.

Participants
In total, 14 triads (40 participants in total) were recruited comprising of an adult with mild/moderate intellectual disability with a history of aggressive challenging behaviour who had received treatment for their behaviours, their carer (paid and/or family), and a health or social care professional involved in their care.We interviewed triads of participants to explore in more depth and from multiple perspectives the convergence and divergence of opinions about the reduction in aggressive challenging behaviour in adults with intellectual disabilities following delivery of a psychosocial intervention.Participants were recruited via social care professionals from seven NHS community intellectual disability services across the UK (i.e., England, Scotland, and Northern Ireland) covering both urban and rural areas.Social care professionals received verbal assent from adults with mild/moderate intellectual disability with a history of aggressive challenging behaviour who had received treatment for their behaviours and their carer (paid and/or family) to be contacted by a researcher to receive detailed information about the study over email, phone or videoconference due to COVID-19 lockdown restrictions.Purposive sampling aimed to achieve participant variation in age, work experience, gender, professional background, and carer roles.
Adults with intellectual disabilities were included if they: 1) had mild or moderate intellectual disability based on service records from the community team; 2) were aged 18 years or over; 3) had received a psychosocial intervention known to reduce challenging behaviour where aggression was the main feature such as verbal of physical aggression to people and/or property; 4) were able to speak English; and 5) provided consent to take part in the study.Carers were included if they: 1) were either a paid or family carer who was well informed of the person's care plan; 2) were aged over 18 years; 3) able to speak English; and 4) provided consent to take part in the study.Health and social care professionals were included if they: 1) were aged 18 years or over; 2) had been involved in the care of the person with intellectual disability; and 3) provided consent to take part in the study.Exclusion criteria for adults with intellectual disabilities included: 1) severe intellectual disability; 2) insufficient verbal ability to take part in the interview; 3) lack of mental capacity to consent.There were no further exclusion criteria for carers and health and social care professionals.

Ethics statement
Recruitment took place between November 2020 and May 2021 which included the period of the second COVID-19 lockdown in the three UK countries (England, Scotland, and Northern Ireland).Verbal audio-recorded informed consent was obtained from all participants which was then transferred to a paper form, as due to COVID-19 lockdown restrictions, we conducted individual interviews with each stakeholder member remotely (e.g., Zoom, Microsoft Teams, telephone calls).The study received NHS Health Research Authority approval from the East of England -Essex Research Ethics Committee (20/EE/0211).

Procedure
Topic guides covered a broad range of topics including views about the nature of the participant's behaviour, type, and experience of support they had received, positive and negative aspects of care and intervention received (Kouroupa et al., 2023).Adults with intellectual disability gave the research team permission to contact their carer (e.g., family and/or paid) and a health and social care professional involved in their care from the local community intellectual disability team (e.g., psychologists, psychiatrist, nurses).Researchers were experienced users of the online communication platforms (i.e., Zoom, Microsoft Teams).The mean duration of interviews was 45 minutes ranging from 18-97 minutes.

Data coding and analysis
Interviews were audio-recorded and transcribed verbatim by an external sponsor approved agency.All identifiable information was removed.Data were analysed using the framework method for thematic analysis of interview transcripts (Braun & Clarke, 2006;Gale et al., 2013;Ritchie et al., 2013).The framework method enabled the open, critical, and reflexive comparison and contrast of data from each triadic group to be compared across themes (Gale et al., 2013).The framework analysis provides a systematic and flexible approach to managing data from different stakeholders and allows for several members of the research team to contribute to data analysis (Gale et al., 2013).It also permits the use of both inductive and deductive approaches (Gale et al., 2013).Data from each participant group was initially analysed separately using NVivo software (version 11).Other qualitative data analysis software with similar functionalities may be used.Following review of the emerging themes and convergence of opinions from all stakeholder groups, themes are presented together.The process included: 1) data familiarisation; 2) identifying themes; 3) indexing of themes; 4) charting and summarising data; 5) interpreting and mapping data; 6) compiling this report.Three researchers (LH, AA, and AR) independently familiarised themselves with five transcripts to develop the initial coding frame for each participant group which was used as a basis for analysis the remaining transcripts.However, as further transcripts were analysed, new codes were added, and the coding frame was continually revised throughout this process.Codes were refined into broader categories (e.g., themes) to systematically explore convergence and divergence across the entire dataset and to develop themes related to facilitators and barriers.

Results
We interviewed 14 adults with intellectual disabilities aged 19-47 years (Mean=33 years old; SD=10).Adults with intellectual disabilities had other neurodevelopmental (e.g., autism, attention deficit hyperactivity disorder) and/or mental health conditions (e.g., schizophrenia, bipolar disorder, anxiety, depression, obsessive compulsive disorder).Just over half of the adults (n=8) were residing in supported living accommodation the others were residing in some form of supported living/residential accommodation.In total, 13 carers took part in interviews most of whom were female (n=11).The mean age of carers was 53 years old (SD=9; range: 41-64 years old).Finally, 13 professionals with a mean of 16 years of employment post-qualification at a community intellectual disability service participated in the study.One paid carer and one health and social care professional participated in two triads each.Details of each triad are presented in Table 1, Table 2 and Table 3.The coding framework was organised into two main domains relating to facilitators of and barriers to positive change (i.e., reduction in aggressive challenging behaviour) (see Figure 1).

Facilitators of positive change following delivery of a psychosocial intervention for aggressive challenging behaviour
Therapeutic and supportive relationships and personalised care were the two main themes reported as having significant influence as to whether psychosocial interventions All stakeholders shared common views on the important components that lead to positive change in adults with intellectual disabilities.

Theme 1: Therapeutic and supportive relationships
The term therapeutic and supportive relationships refer to the therapeutic alliance of carers (e.g., family and paid) and adults Rapport and relationship building Developing a close and trusting relationship among all parties was important to all stakeholders.Professionals acknowledged that active listening to the person with intellectual disability and their carers (e.g., paid or family) facilitated better engagement in the intervention.
"The best treatment was the rapport…it took a few times to develop...If you press the right buttons…you need to have the confidence of the patient… Listening to them is very important.Initially he would not engage much, but once he built a rapport with us, then he was keen… more motivated to attend…It is a slow process."(Consultant Psychiatrist) People with intellectual disabilities and family carers emphasised the importance of the therapist's positive interpersonal skills which motivated them to attend the sessions.
"They're funny, they're kind.They're enthusiastic, they're lovely.They help me to do things that I've never done before."(Adult with intellectual disability) Both adults with intellectual disabilities and family carers described how feeling genuinely listened to by professionals was important in developing trust and highly valued if they were to engage in an intervention.
with intellectual disabilities with health and social care professionals and the broader supportive relationships of carers (e.g., family and paid) with adults with intellectual disabilities.
" Finally, the motivation of the adult with intellectual disability was a crucial enabling factor in promoting engagement in therapy.
" [800011]'s attitude to the therapy was brilliant.He really wanted to engage with it.There was a real desire to make changes…he was sort of a dream client really…as a credit to him he was so keen to come along and change."(Assistant Psychologist)

Consistency in communication
Professionals focused on the role of carers (i.e., family or paid) as agents for intervention delivery and success.
"Having a small predictable support staff team was really vital…they had fewer people coming and going and he built a better relationship with them…they weren't constantly revolving; they were a stable team which is really fantastic."(Assistant Psychologist) Professionals valued working with family carers and adults with intellectual disabilities to achieve a reduction in aggressive challenging behaviour and improve quality of life.Agreed care plans informed through discussions with both family carers and the person with intellectual disability led to a collaborative approach that increased confidence in the support network of a positive outcome.Finally, adults with intellectual disability and professionals reported that the choice of words play a significant role in people's engagement with services.
"Yes, I don't like when some people say loads of words that can trigger me.But she [health and social care professional] was nice" (Adult with intellectual disability) "He did mention…Psychology.I think he said, no and then with the behaviour support plan and all that, he sort of accepted, because the word Psychology is not there."(Nurse)

Therapy formats and preparedness
The frequency and format of the intervention received were also seen as potential points for reasonable adjustments to maximise engagement in therapy.
"…there was a social element to the DBT…she was going along as part of a group.she enjoyed meeting new people, although it was difficult to begin with.Once she was established in the group, she enjoyed the company.She enjoyed the social element of that there."… it's not through lack of trying.I've just had the second referral for specialist psychology refused…he's been consistent in saying he wants psychology input, and unfortunately, he's not meeting the criteria for them to accept him because of his level of alcohol abuse and intoxication, they don't believe that he's in a place where he's willing to buy into therapy and engage with it … There are some system failings…there are also some rigid criteria that he failed to meet which is inflexible."(Nurse) "They get the psychologist involved when things were really difficult…Unfortunately, it tended to be short bursts he would get…he would see a psychologist for maybe two or three months and then they would back off.Then when things got tough again, they would say oh, we will re-refer him.Then we had to go through the whole process all over again."(Family carer) Similarly, professionals emphasised that there are some carers who seek a 'quick fix' and become pessimistic when aggressive challenging behaviour persists often in the face of multiple cycles of an intervention.
"…she doesn't consider that things have changed that much…I think her expectation is that she's suddenly going to change completely."(Clinical Psychologist)

Readiness for therapy
Professionals reported that it is often the case that carers find it challenging to implement the strategies suggested in the PBS plan consistently with adults with intellectual disabilities, therefore, aggressive challenging behaviours may be maintained.Regardless of the support and/or training provided, some individuals have additional needs which affect the care that is provided if not tailored to the specific individual needs.
"Although we tried to support the family to implement some of these strategies at home this has been very hard due to her father's learning disabilities and her mother's mental health issues.It's difficult for them to process this information…his parents were not able to implement any recommendations that were being made to them.There are some also language barriers."(100024 -Professional) ).The input of family carers in care plans is undisputable.A consistent approach to implementing care plans across services followed by ongoing family involvement, is equally crucial to lead to a positive change.Future research should determine whether psychosocial interventions have been implemented as intended and result in the reduction of aggressive challenging behaviour in adults with intellectual disabilities in community and/or other settings.Future studies might consider interviewing carers (e.g., family and/or paid), adults with intellectual disabilities and professionals altogether rather than separately to gain a more in-depth knowledge and understanding of the facilitators and barriers in achieving reduction in aggressive challenging behaviour.In the future, studies could also attempt to identify the most important personal attributes of professionals and obtain a better understanding of the nature of the relationship between the adult with intellectual disabilities and the professional involved in their care.Finally, while psychoeducation of carers to better understand the presence of aggressive challenging behaviour is important, it is equally essential for professionals to establish positive relationships with family/paid carers and/or adults with intellectual disability, where possible, and discuss with sensitivity the degree of expected and desired change of these behaviours to increase motivation and engagement with services.

Strengths and limitations
This study examines the experiences of multiple stakeholders about the perceived facilitators and barriers of delivering psychosocial interventions to address aggressive challenging behaviour in adults with intellectual disabilities across UK services.This is particularly important as current guidelines emphasise the use of non-pharmacological interventions for the management of behaviour that challenges and reducing the inappropriate prescription of psychotropic medications in adults with intellectual disabilities (Branford et al., 2018;NICE, 2015).This study collected a large amount of data from participants who had received individual psychosocial therapies such as CBT to network wide support including PBS to address aggressive challenging behaviour.Nonetheless, the study findings do not represent the views of adults with severe intellectual disabilities who may have a very different experience of care, because almost all suitable psychosocial interventions are provided via proxy.In addition, the voices of adults with mild/moderate intellectual disability remain a minority compared to carers and professionals.
Collecting qualitative data from a large number of stakeholders meant that analysis of the different perspectives across the triads was also limited.Recruitment in the study began in November 2020 during the COVID-19 pandemic which might have introduced selection bias.It is likely that participants with strong views on the topic or positive relationship with professionals were keen to participate in the study.There was, also, limited representation of triads from Northern Ireland and Scotland, with only one and two triads from each country, respectively.Yet, views appear to converge across participants from all three countries and the care systems for people with intellectual disabilities are broadly organised in a similar way in the three countries.Finally, we acknowledge that this may be a limited outcome as often the emphasis is also on improving quality of life which may lead to the eventual reduction of aggressive challenging behaviour.However, the latter is the commonest reason for referral to the community intellectual disability services and many behavioural interventions are tailored to confer immediate alleviation of the risk of injury to self and/or others and to avoid other consequences such as destruction of the environment.

Conclusion
Adults with intellectual disabilities who display aggressive challenging behaviour face numerous challenges to accessing psychosocial therapies.There is a gap in care plans being developed with input from family and/or paid carers and adults with intellectual disabilities, and the implementation of care plans in daily practice.The present study gave an overview of multiple stakeholder's experiences of the value of therapeutic and supportive relationships and personalised care in psychosocial interventions to address aggressive challenging behaviour in adults with intellectual disabilities.It also described ongoing challenges within community intellectual disability services with negative outcomes for the implementation of psychosocial interventions.Social care funding should be at the forefront of any mental health policy briefing, and this includes establishing a good network of support to carers of adults with intellectual disabilities as well as high quality and consistent support to people with intellectual disabilities.Providing this broader input is an important and often overlooked avenue of professional support and is key to improving outcomes for those who display aggressive challenging behaviour.Nonetheless, these service improvements require shared knowledge and understanding of the need to adapt interventions for adults with intellectual disabilities among NHS staff members.Regardless of the improvements in the health and social care provision for adults with intellectual disabilities over the years, there are still serious implementation barriers that likely compromise the effectiveness of psychosocial interventions.Future research should focus on the processes and factors that facilitate high-quality and consistent support to adults with intellectual disabilities and their carers.potential worth of interviewing the members of the triad together.Inevitably there are issues of research ethics that will influence such design decision.
The topics of the semi-structured interviews that were obtained from the 'expert by experience' as well as the researchers from their review of research examined in the introduction of the report.

2.
Whilst the method described here is in keeping with the deductive method of Framework Thematic Analysis, this does raise issues that need attention in the discussion or limitation of the study.What were the criteria for selecting the 5 transcripts that provided the initial coding of the data?How did these 5 transcripts represent the 3 types of stake holders?I am of the view that this procedure merits further justification.When one looks for certain code in such a rich set of qualitative data, one inevitably finds what one is looking for at the risk of missing other information that may be pertinent to one's research question/s.

3.
The interpretations of the themes are richly supported by excerpts from the interview transcripts, however when I read the excerpts from the professionals, I am intrigued to find out about their professions… This research makes a significant contribution to knowledge about psychosocial interventions in the lives of intellectually disabled people, their carers/supporters and therapists.Its ethos of inclusivity and attention to the voices of intellectually disabled people, who are also 'experts by experience', is exemplary.Dagnan (2007)  2 literature review identifies psychosocial interventions as occurring at four levels.It strikes me that the discussion about 'facilitators and barriers' of such interventions, identified here, would benefit from addressing these levels.In particular it seems that some of the barriers are occurring at the social and service/organisational levels, whilst the facilitators occur at the individual or relational level.
Finally, good research evokes new research questions.Questions such as: What are the personal attributes of talented psychosocial therapists?
○ What is the nature of the relationship between the person who experiences learning difficulties and the therapist who facilitates positive outcomes for the latter?

Reviewer Expertise: Intellectual Disabilities and Qualitative Methodologies
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
Author Response 02 Dec 2023

Athanasia Kouroupa
Whilst I understand that a report such as this cannot attend to everything, attention to the following would add to the validity and replicability of this important work: 1.More information about how and where the interviews were conducted.It appears that the participants were interviewed individually.The discussion could take up the issue about the potential worth of interviewing the members of the triad together.Inevitably there are issues of research ethics that will influence such design decision.
Our response: Thank you for the comment.The researcher interviewed each participant separately.The study procedures section has been updated accordingly (line 125).All interviews were conducted online as a result of the COVID-19 lockdown restrictions (line 135).The discussion has been amended (line 539-545).
2. The topics of the semi-structured interviews that were obtained from the 'expert by experience' as well as the researchers from their review of research examined in the introduction of the report.
Our response: This is an accurate reflection of the Patient and Public Involvement section.
3. Whilst the method described here is in keeping with the deductive method of Framework Thematic Analysis, this does raise issues that need attention in the discussion or limitation of the study.What were the criteria for selecting the 5 transcripts that provided the initial coding of the data?How did these 5 transcripts represent the 3 types of stake holders?I am of the view that this procedure merits further justification.When one looks for certain code in such a rich set of qualitative data, one inevitably finds what one is looking for at the risk of missing other information that may be pertinent to one's research question/s.Our response: Thank you for your comment.The data coding and analysis section has been revised (line 154-156).
The interpretations of the themes are richly supported by excerpts from the interview transcripts, however when I read the excerpts from the professionals, I am intrigued to find out about their professions… Our response: Thank you for your comment.The quotes from professionals now include their professions.
This research makes a significant contribution to knowledge about psychosocial interventions in the lives of intellectually disabled people, their carers/supporters and therapists.Its ethos of inclusivity and attention to the voices of intellectually disabled people, who are also 'experts by experience', is exemplary.Dagnan (2007) literature review identifies psychosocial interventions as occurring at four levels.It strikes me that the discussion about 'facilitators and barriers' of such interventions, identified here, would benefit from addressing these levels.In particular it seems that some of the barriers are occurring at the social and service/organisational levels, whilst the facilitators occur at the individual or relational level.
Our response: Thank you for the suggested literature.The discussion has been amended (line 506-509 and line 524).
Finally, good research evokes new research questions.Questions such as: What are the personal attributes of talented psychosocial therapists? 1.
What is the nature of the relationship between the person who experiences learning difficulties and the therapist who facilitates positive outcomes for the latter?2.
Our response: Thank you for the comment.The discussion section has been updated accordingly (line 540-545).
Additional Review from Dr Mark Haydon-Laurelut, Senior Lecturer, Department of Psychology, University of Portsmouth A limitation to the article is the notion of 'psychosocial interventions.The approaches described have very significant differences ranging from individual psychological therapies such as Cognitive Behaviour Therapy (CBT) to network wide behavioural assessment and planning (Positive Behaviour Support).Our response: Thank you for the comment.The relevant section has been amended (line 559).
Please consider rewording the following: 'Psychosocial interventions aim to meet unmet needs of adults with intellectual disabilities including housing, self-care, social and interpersonal skills, daytime activities, and housekeeping for those in family, supported or residential care homes (Gustafsson et al., 2009)'.Therapies (for example psychological therapies such as CBT) do not routinely attempt to meet the 'housing needs' and 'housekeeping' of clients.Additionally, discussion of for example: 'a gap in care plans being developed with input from family and/or paid carers and adults with intellectual disabilities, and the implementation of care plans in daily practice' fits clearly with some service/network approaches such as PBS and less to individual psychological therapies/psychotherapies. Our response: Thank you for the comment.This is a broad definition of psychosocial interventions offered to adults with intellectual disabilities who display aggressive challenging behaviour.In this study, we do not only target individual psychosocial therapies such as Cognitive Behaviour Therapy (CBT).We also refer to network-wide behavioural support such as Positive Behaviour Support, first-line therapy in the UK NHS and other social supports that may also lead to quality of life improvements.Therefore, we have decided not to reword the sentence to be inclusive of the psychosocial support offered to this population.
Overall, the very broad categorisation of psychosocial interventions works as a limitation of the research, and it is suggested this could be added to the appropriate section.Our response: Thank you for the comment.The relevant section has been amended (line 559).
The discussion notes that: 'In addition, there is scarce understanding of how those who receive these interventions experience them and what their expectations are…' Any studies that do exist that address this issue should be cited here.Our response: Thank you for the comment.The discussion has been amended (line 529).

Methods
Further information on framework analysis would be useful as well as the advantages and disadvantages of mixed inductive and deductive analytic aspects.Our response: Thank you for the comment.The relevant section has been amended (lines 143-146).
Competing Interests: No competing interests were disclosed.
Reviewer Report 29 August 2023 https://doi.org/10.3310/nihropenres.14575.r30307 The scientific literature is properly integrated and cited.However, it would be useful to better define what is meant by "psychosocial intervention" within the introduction.Indeed, this term can cover relatively broad practices and services, and insofar as the question of access and that of evidence-based practices are raised later in the discussion, it would be useful to be able to better delimit the concept and its applications.
Study design and methodological options are appropriate to the research questions.A strength of the study is the use of an inclusive research design involving panels of people with intellectual disabilities and carers in the design of the study, as well as considering the perspective of triads (people with intellectual disabilities-carer-professional).
Overall, the manuscript provides sufficient details of methods and analysis for replication.However, some missing information would appear to be relevant.It wasn't entirely clear to me to what extent the stakeholders and/or the panel of experts by experience had been involved in analysing the data.Besides, I did not fully understand if participants were actually met once (in "triads") or did the researcher met each stakeholder at different occasion.
Providing an overview of the interview guide would be interesting for future research.
It would be interesting to have a better idea of the relative weight of each theme and sub-theme within the analyses.In addition, the discussion mentions that certain issues were more relevant for people with intellectual disabilities than for carers or professionals, and vice versa; but the presentation of the results as they stand does not make it possible to determine in which theme or sub-themes the units of meaning linked to the discourse of people with intellectual disabilities were more or less present.This information would make it easier to understand the data.
Similarly, if relevant, it would be useful to have a perspective in relation to 'sites', as it is suggested that perspectives are consistent across these in the discussion.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?Not applicable Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Disability studies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
better define what is meant by "psychosocial intervention" within the introduction.Indeed, this term can cover relatively broad practices and services, and insofar as the question of access and that of evidence-based practices are raised later in the discussion, it would be useful to be able to better delimit the concept and its applications.Our response: Thank you for the comment.The manuscript provides a definition in line 20-22.
It wasn't entirely clear to me to what extent the stakeholders and/or the panel of experts by experience had been involved in analysing the data.Besides, I did not fully understand if participants were actually met once (in "triads") or did the researcher met each stakeholder at different occasion.Our response: Thank you for the comment.The advisory groups were actively involved at all stages of the study (line 85-90).They also reviewed and commented on the emerging themes and sub-themes during the coding phase.The researcher met each participant separately to conduct 1:1 interviews.The procedures section has been updated accordingly (line 125).
Providing an overview of the interview guide would be interesting for future research.Our response: Thank you for your comment.The topic guides are available via Zenodo (see data availability section).
It would be interesting to have a better idea of the relative weight of each theme and subtheme within the analyses.In addition, the discussion mentions that certain issues were more relevant for people with intellectual disabilities than for carers or professionals, and vice versa; but the presentation of the results as they stand does not make it possible to determine in which theme or sub-themes the units of meaning linked to the discourse of people with intellectual disabilities were more or less present.This information would make it easier to understand the data.Similarly, if relevant, it would be useful to have a perspective in relation to 'sites', as it is suggested that perspectives are consistent across these in the discussion.Our response: Thank you for your comment.In this study, our aim was to provide a range of views and perspectives from multiple stakeholder members in intellectual disabilities.In keeping with other qualitative research, we have decided not to incorporate numbers (or weights) as it can lead to inferences about the generality of findings, which may be inaccurate or not justified given the interpretative nature of the analysis.
The most common psychosocial interventions reported by all stakeholders were Positive Behaviour Support (n=7), Cognitive Behaviour Therapy (n=5) and Dialectical Behaviour Therapy (n=2).Only one person had received all three psychosocial interventions.

Table 2 . Socio-demographic characteristics of carers. Characteristics Carers (n=13)
in adults with intellectual disabilities led to reduction in aggressive challenging behaviour(Kouroupa et al., 2023).
That she[therapist]understood what I was saying.She'd[therapist]give examples how to help and that... Willing to talk about it and not just shutting it off."(Adultwithintellectualdisability) "… they've all really taken onboard what the difficulties are for[1100011], and for us as well.I really genuinely feel that just being listened to has made a huge difference."(Familycarer)Past negative experiences such as not being able to access services, care pauses or discontinuation and/or distrust of professionals appeared to influence current contacts with professionals as reported by both carers, particularly family carers, and adults with intellectual disabilities.Therefore, setting new expectations can also be beneficial in forming new positive contact.
"…I have managed to establish a positive relationship with mum… that has been really important because it would have been really easy to disengage from the family because mum, she doesn't trust us.It would have been very easy for her, if we hadn't been very careful in the way we had set things up around them, to disengage."(Clinical Psychologist) "I don't tell anybody unless I trust them [therapists]…if it's a new member of staff, I clam up…because I've been hurt that many times."(Adult with intellectual disability)

"
The best training possibly that we've had was actually family, was informal training for his mum and his sister.So, we linked in with the family, with the health professionals, with their own internal training.So, it was quite comprehensive across the board."(Social Worker) "She understood what I was saying.She'd give examples how to help and that...Willing to talk about it and not just shutting it off."(Adult with intellectual disability) "…We would have struggled without the support.Sometimes it just takes a fresh set of eyes coming in to see what we're doing, reviewing the paperwork, and trying to make suggestions of what we could potentially try and do to improve it…" (Paid carer)Family and paid carers focused on the importance of effective information sharing between professionals and carers to ensure a consistent approach is implemented across different contexts."…Everybodysingingfrom the same hymn sheet.I have spoken to all the staff that works with[1100021] and I have made it very clear to them.You all need to be doing the same thing.It doesn't work with [1100021Theme 2: Personalised care Personalised care is defined as "supporting people with intellectual disabilities to build a lifestyle based on choices, preferences, shared power, rights and inclusion" (Ratti et al., 2016).Professionals reported that other factors such as humour may also improve engagement in a therapeutic conversation."…humour is a really good way to get [100021] engaged and positive, away from the negative… [100021]'s a big [football team] fan…he loves talking about that….that's a really good way of coaxing [100021]."(Social Worker) to appropriate psychosocial interventions to address aggressive challenging behaviour in adults with intellectual disabilities but also likely to lead to potentially adverse consequences for the person with intellectual disability.
And then they could have a chat afterwards."(ClinicalPsychologist)"Wouldn'tdowell in group therapy… he wouldn't be able to concentrate, and also, he probably wouldn't open us as much as he can do when it's a one to one.Other staff members have to interpret it a little bit different if you're in a group therapy you don't upset your carer when you're doing it in front of everybody, because otherwise he'd feel that you're being put down in front of people and there's all those massive impacts on them."(Paidcarer)intellectualdisabilitiesfocused on the problematic aspects at an operational level that impeded access to psychosocial support for aggressive challenging behaviour in adults with intellectual disabilities.The two main themes reported as a barrier were navigating through the system and service constraints and therapy delivery challenges."Yes,resourcesarealwaysshort, isn't it?If he had a CBT therapist, people within IAPT, they don't think he can do CBT…but I have done that model and I have found that he was going home, and he was maintaining the diary and he was coming back and talking about, there are alternative options."(ConsultantPsychiatrist)Furthermore,professionals emphasised the difficulty in accessing clinic space to arrange sessions with adults with intellectual disabilities and/or carers."Iwishwe'dhave had more access to facilities.I think part of the issue with the work that we did was with wanting to be consistent in terms of time and place.Access to NHS and social care resourcesAll stakeholders highlighted that service gaps (i.e., shortage of certain professions, e.g., psychologists and nurses leading to long waiting lists for psychological support) in community intellectual disability services across different areas not only limit access …but at times of crisis she really struggled with actually engaging in them...if you were to prompt…she'll just look at you, but her eyes will be really wide…she can't even process and there is a cognitive delay from one of the previous overdoses that she had taken…" (Paid carer) (Bambara et al., 2001;Bradshaw et al., 2004;ave to disagree to agree at some points and see where things are going."(Paidcarer)Finally,professionals and paid carers highlighted that adults with intellectual disabilities may not always be 'ready' to engage in therapy due to a mental health condition."withinthesameteam, strict referral criteria to specialist services for adults with intellectual disabilities that can complicate the care pathway, high staff turnover and limited access to psychosocial therapies (Brown et al., 2016; Dagnan, 2007; Flynn et al., 2018; Hassiotis et al., 2022a; Marwood et al., 2018).Research indicates that simplifying these procedures enhances engagement with professionals and therapy and facilitates behavioural change (Botterill et al., 2019).There is scarce data to evaluate the implementation of psychosocial interventions for aggressive challenging behaviour in adults with intellectual disabilities to compare with this work(Bambara et al., 2001;Bradshaw et al., 2004; Davies et al.,  2021; Lindsay et al., 2003; Willner et al., 2013).

Review from Dr Mark Haydon-Laurelut, Senior Lecturer, Department of Psychology, University of Portsmouth
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