Complex interventions for aggressive challenging behaviour in adults with intellectual disability: A rapid realist review informed by multiple populations

Rachel Royston; Stephen Naughton; Angela Hassiotis; Andrew Jahoda; Afia Ali; Umesh Chauhan; Sally-Ann Cooper; Athanasia Kouroupa; Liz Steed; Andre Strydom; Laurence Taggart; Penny Rapaport

doi:10.1371/journal.pone.0285590

Peer Review History

Original SubmissionFebruary 21, 2023
4 Apr 2023 Decision Letter - Weifeng Han, Editor PONE-D-23-05137Complex interventions for aggressive challenging behaviour in adults with intellectual disability: a rapid realist review informed by multiple populationsPLOS ONE Dear Dr. Royston, Thank you for submitting your manuscript to PLOS ONE. Two reviewers have evaluated your manuscript and minor revisions are recommended. Therefore, I invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by May 19 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study aimed to explore the mechanisms that contribute to the successful implementation of interventions for aggressive challenging behavior in individuals with intellectual disability. The review included 59 studies and developed three domains and 11 context-mechanism-outcome configurations. Overall, the study highlights the importance of person-centered approaches, team-focused approaches, and sustaining and embedding facilitating factors at team and systems levels. The methodology used for this review is reasonable and comprehensive. The study offers novel insights into the mechanisms that contribute to successful interventions for aggressive challenging behaviors in individuals with intellectual disability. It is also noted that the study limitations have been appropriately listed. Reviewer #2: It is so interesting and well written article. But some minor comments could be addressed. 1- The discussion is well written and organized but the authors did not discuss regarding their results about main findings. 2-It is better the aims and research questions wrote more clearly. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Marsa Gholamzadeh ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0285590.r001
Revision 1
25 Apr 2023 Author Response Dear Editors, Thank you for your consideration and comments on our manuscript “Complex interventions for aggressive challenging behaviour in adults with intellectual disability: a rapid realist review informed by multiple populations” (PONE-D-23-05137). We would like to thank both reviewers for their comments and suggestions on the manuscript. We have addressed the following points: Reviewer #1: The study aimed to explore the mechanisms that contribute to the successful implementation of interventions for aggressive challenging behavior in individuals with intellectual disability. The review included 59 studies and developed three domains and 11 context-mechanism-outcome configurations. Overall, the study highlights the importance of person-centered approaches, team-focused approaches, and sustaining and embedding facilitating factors at team and systems levels. The methodology used for this review is reasonable and comprehensive. The study offers novel insights into the mechanisms that contribute to successful interventions for aggressive challenging behaviors in individuals with intellectual disability. It is also noted that the study limitations have been appropriately listed. Response: We would like to thank this reviewer for their positive review of our manuscript, and we are pleased the reviewer agrees that this study offers novel insights in this topic area. Reviewer #2: It is so interesting and well written article. But some minor comments could be addressed. 1- The discussion is well written and organized but the authors did not discuss regarding their results about main findings. 2-It is better the aims and research questions wrote more clearly. Response: 1 – The ‘key findings’ section in the discussion outlines the main results of the study. We have edited this section to map the content of this section more closely to the final programme pathway figure (Figure 4). We hope this clarifies the main findings of the study in line with this suggestion. The changes to the text have been highlighted below in bold. ‘We identified emotional regulation training, sensory based approaches, and the inclusion of meaningful activities as key components of complex interventions that can effectively support people to reduce aggressive challenging behaviour, improve relationships and the person’s quality of life. These approaches work through enriching the environment, addressing unmet needs and through facilitating the development of positive skills. However, approaches that require more cognitive and communicative abilities (i.e. learning skills to control and manage emotions or directly learning mindfulness techniques) may only be appropriate for the subset of the population with milder intellectual impairment [39, 88]. Many available interventions are administered to people with intellectual disability regardless of severity and this may be over-inclusive and ineffective, as some people may not have the capacity to benefit from the chosen approach. Hence, interventions should be specifically chosen to suit an individual’s ability level and a suitable intervention duration needs to also be considered. Positive outcomes can be further facilitated when elements of chosen interventions are further personalised and tailored to the person and when there is an opportunity for individuals, carers and staff to practice and embed the skills they learn. The majority of behavioural change interventions in the general population focus on the individual [89, 90], however it is evident from our review that carer involvement and collaborative relationships are crucial to facilitate and sustain change in cognitively impaired populations. Family and paid carers are often on the receiving end of aggressive challenging behaviour, which affects their relationship with the person, as well as how they interact and respond when incidents occur. Carers often also experience burnout and may lack motivation and confidence [91, 92], therefore interventions that address these barriers (e.g. through improving awareness and understanding, enhancing carer compassion and empathy) are equally essential to reduce carer stress, increase efficacy, build trust and improve outcomes. To enhance the acceptability of interventions, there also needs to be an additional focus on effective delivery and implementation, through providing adequate training, protected time to practice skills, collaborative working within teams, and through continual mentorship and support to staff [93]. The quality of staff training in an intervention may be more influential in supporting the achievement of desired outcomes than the content or characteristics of the intervention itself [94]. Thus, it is essential for there to be buy-in at senior management level to ensure appropriate training is delivered and to provide cohesion, clear leadership and a supportive and motivating environment. This will promote therapist self-efficacy and motivation to deliver the intervention, leading to higher intervention fidelity and greater engagement and satisfaction from recipients.’ (Pages 26-27, lines 470-505). 2 – We agree that the research aims and questions could be stated more explicitly. We have revised the end of the introduction as follows: ‘This study aims to conduct a rapid realist review and develop a set of programme theories to explore how complex interventions work to reduce aggressive challenging behaviour, under which circumstances and for whom. Specifically, we will investigate: 1) Which interventions or intervention components work best to reduce aggressive challenging behaviour 2) Which contexts support or hinder their effectiveness 3) What are the key mechanisms that impact on the delivery, engagement and success of complex interventions Where possible, we aim to identify key features of individuals with intellectual disability and of family and paid carers who respond differentially to complex interventions for aggressive challenging behaviour within care systems. In addressing these aims, we have integrated complementary approaches in our methodology: Identification of initial programme theories on what may sustain medium to long term change in treatment impact and practice; and a qualitative interview analysis to test these theories and factors associated with uptake and interventions delivery in routine care.’ (Page 4, lines 76-90) We hope these changes are considered as satisfactory by the reviewers. Please let us know if you require any additional information. We look forward to hearing from you. Kind regards, Rachel Royston, Stephen Naughton, Angela Hassiotis, Andrew Jahoda, Afia Ali, Umesh Chauhan, Sally-Ann Cooper, Athanasia Kouroupa, Liz Steed, Andre Strydom, Laurence Taggart & Penny Rapaport. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0285590.r002
27 Apr 2023 Decision Letter - Weifeng Han, Editor Complex interventions for aggressive challenging behaviour in adults with intellectual disability: a rapid realist review informed by multiple populations PONE-D-23-05137R1 Dear Dr. Royston, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Weifeng Han, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0285590.r003
Formally Accepted
10 May 2023 Acceptance Letter - Weifeng Han, Editor PONE-D-23-05137R1 Complex interventions for aggressive challenging behaviour in adults with intellectual disability: a rapid realist review informed by multiple populations Dear Dr. Royston: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Weifeng Han Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0285590.r004

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