Publications & Bibliography

@article{Firth2020,

title = {A qualitative study of the practice‐related decision‐making of Intensive Interaction practitioners},

author = {Graham Firth and Megan Glyde and Gemma Denby},

doi = { https://doi.org/10.1111/bld.12355},

year  = {2020},

date = {2020-11-06},

journal = {British Journal of Learning Disabilities},

volume = {49},

issue = {2},

pages = {117-128},

abstract = {Accessible summary



People who use Intensive Interaction want to find the best ways to enjoy interacting with people with learning disabilities and/or autism. This study is about how the people who use Intensive Interaction (in this study called “practitioners”) decide how best to do it, often as they go along.



This study found that the practitioners who use Intensive Interaction with people with learning disabilities and/or autism think about a lot of different things. They think about some things before they start doing Intensive Interaction with a person, other things while they are doing the Intensive Interaction and some more things when they have finished.



The study also says that the practitioners who use Intensive Interaction could do it even better if they thought about it more or watched some video of their Intensive Interactions, either on their own or with the help of some other people who also do Intensive Interaction.



Background



This study looked to investigate the sometimes conscious and sometimes intuitive decision-making processes of Intensive Interaction practitioners. More specifically, this study set out to develop a rich description of how practitioners make judgements when developing a dynamic repertoire of Intensive Interaction strategies with people with severe or profound learning difficulties and/or autism, how this decision-making process is enacted in practice and what issues inform such decisions.



Materials and Methods



This research followed a “Template Analysis” qualitative methodology, informed by semi-structured interviews with 13 experienced Intensive Interaction Practitioners (who had completed the Intensive Interaction Coordinators course as administered by the Intensive Interaction Institute). The participants included the following: speech and language therapists, parents, teachers, residential care staff and managers, and a clinical psychologist.



Results



The findings of this study indicate why and how certain decisions are made by experienced practitioners before, during and after engagement in Intensive Interaction. Such decision-making is indicated as sometimes being intuitive in nature, sometimes more conscious, sometimes moving between the two cognitive states as differing issues arise.



Practitioner decision-making was focused on a number of issues, including specific learning or care “agendas”; practitioner confidence and knowledge; environmental considerations; individual learner characteristics and behaviour; learner attention, “attunement” and arousal levels; building a shared “repertoire”; and issues of available time.



Conclusions



The issue of how novice Intensive Interaction practitioners may best be supported to more quickly and confidently develop improved Intensive Interaction practices is discussed, proposing the development of a cyclical process of experiential learning and supported reflection.

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Close

Accessible summary

People who use Intensive Interaction want to find the best ways to enjoy interacting with people with learning disabilities and/or autism. This study is about how the people who use Intensive Interaction (in this study called “practitioners”) decide how best to do it, often as they go along.

This study found that the practitioners who use Intensive Interaction with people with learning disabilities and/or autism think about a lot of different things. They think about some things before they start doing Intensive Interaction with a person, other things while they are doing the Intensive Interaction and some more things when they have finished.

The study also says that the practitioners who use Intensive Interaction could do it even better if they thought about it more or watched some video of their Intensive Interactions, either on their own or with the help of some other people who also do Intensive Interaction.

Background

This study looked to investigate the sometimes conscious and sometimes intuitive decision-making processes of Intensive Interaction practitioners. More specifically, this study set out to develop a rich description of how practitioners make judgements when developing a dynamic repertoire of Intensive Interaction strategies with people with severe or profound learning difficulties and/or autism, how this decision-making process is enacted in practice and what issues inform such decisions.

Materials and Methods

This research followed a “Template Analysis” qualitative methodology, informed by semi-structured interviews with 13 experienced Intensive Interaction Practitioners (who had completed the Intensive Interaction Coordinators course as administered by the Intensive Interaction Institute). The participants included the following: speech and language therapists, parents, teachers, residential care staff and managers, and a clinical psychologist.

Results

The findings of this study indicate why and how certain decisions are made by experienced practitioners before, during and after engagement in Intensive Interaction. Such decision-making is indicated as sometimes being intuitive in nature, sometimes more conscious, sometimes moving between the two cognitive states as differing issues arise.

Practitioner decision-making was focused on a number of issues, including specific learning or care “agendas”; practitioner confidence and knowledge; environmental considerations; individual learner characteristics and behaviour; learner attention, “attunement” and arousal levels; building a shared “repertoire”; and issues of available time.

Conclusions

The issue of how novice Intensive Interaction practitioners may best be supported to more quickly and confidently develop improved Intensive Interaction practices is discussed, proposing the development of a cyclical process of experiential learning and supported reflection.

Close

Shearer, Katherine; Parkhouse, Charlotte

Intensive interaction: an evaluation of two different recording formats Journal Article

In: Good Autism Practice , vol. 21, no. 2, pp. 23-32, 2020, ISSN: 1466-2973 Print; 2046-5521 Online.

Abstract | Links | BibTeX

Karimi, Sara; Asgari, Parviz; Heydari, Alireza

The effect of intensive interaction intervention on the social interactions and communication of children with autism spectrum disorder Journal Article

In: Jundishapur Scientific Medical Journal, vol. 18, iss. 6, pp. 603-614, 2019.

Abstract | Links | BibTeX

@article{Karimi2019,

title = {The effect of intensive interaction intervention on the social interactions and communication of children with autism spectrum disorder},

author = {Sara Karimi and Parviz Asgari and Alireza Heydari},

doi = {10.22118/jsmj.2020.206834.1885},

year  = {2019},

date = {2019-03-01},

journal = {Jundishapur Scientific Medical Journal},

volume = {18},

issue = {6},

pages = {603-614},

abstract = {Background and objects: Autism spectrum disorder is one of the disorders of growth, and so far, different methods have been developed to reduce its symptoms. In this research, the method of intensive interaction has been studied. The purpose of this study was to investigate the effectiveness of intensive interaction intervention on social interactions and communication of children with autism spectrum disorder.

Method: This study is due to the use of a non-randomized, semi-experimental with control group and pretest, post-test. The population of this study included children with autism spectrum disorder that was selected by available sampling among the centers of autism in Ahvaz, Iran, and 11 children were randomly assigned to both experimental and control groups. The Gilliam Autism Scale (Gars) was used to measure the variables of the research. To analyze the results, descriptive statistics including mean and standard deviations of scores were used and the covariance analysis was used to control the interventional variables in the pretest.



Conclusion: According to the findings, the method of interactive interaction is effective on the social interaction dimension, but it is not effective on the communication. communication mainly involves the use of language and is more specific than interaction in general. Therefore, the effectiveness of this method was confirmed on social interaction but was not confirmed by social communication.

Kay words: autism, intensive interaction intervention, social interaction, communication},

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pubstate = {published},

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Close

Heap, Cheyann J; Wolverson, Emma

Intensive Interaction and discourses of personhood: A focus group study with dementia caregivers Journal Article

In: Dementia, 2018, ISSN: 1471-3012.

Abstract | Links | BibTeX

@article{Heap2018,

title = {Intensive Interaction and discourses of personhood: A focus group study with dementia caregivers },

author = {Cheyann J Heap and Emma Wolverson},

doi = {10.1177/1471301218814389},

issn = {1471-3012},

year  = {2018},

date = {2018-12-04},

journal = {Dementia},

abstract = {Introduction: According to the authors of this paper, due to ‘the medicalisation of dementia … dehumanising social practices and attitudes are enabled, and reinforced by medical discourses of dementia which have become societal discourse … Within the medical societal discourse, people with dementia are excessively medicated.’ Also, ‘Intensive Interaction assumes that all interaction partners can be meaningfully engaged [and] … can offer an alternative to medicalised discourses (and by proxy, the dehumanising practices enabled by such discourses).’ 



Study Method: Paid staff from two residential care homes attended an Intensive Interaction training day. These caregivers took part in 2 focus groups before and after the Intensive Interaction training. Transcripts of the focus groups were then analysed using the method of Critical Discourse Analysis, an approach which ‘relates discourse to social power’. The focus group discussion were based on 5 themes identified as missing in medical/societal discourse: ‘personhood’, ‘communication’, ‘embodiment’, ‘reciprocity’ and ‘empathy’. 



The Results: Before the Intensive Interaction training carers engaged in ‘medical discourses of loss, non-communication and lack of personhood’. Carers also talked about a lack of resources (time and staff), with job role/hierarchy being important in allowing time (and permission) to interact with residents. “Being with” people with dementia was framed as ‘inactivity’ (‘sitting’, not ‘working’) or ‘a luxury, and therefore separate to paid work within ‘an industrial model’. 



After training, caregivers engaged in ‘discourses of communication and personhood’. Intensive Interaction reframed “being with” people as a part of ‘doing work’. Staff viewpoints significantly shifted with carers talking about going ‘into the world’ of the person with dementia, and they also thought that ‘Intensive Interaction would improve relationships’. Intensive Interaction was also seen to ‘legitimise and explain existing relational and creative practices’. However, there were worries that managers might be critical of the approach ‘unless they had training to understand the discourse (e.g. ‘mirroring’ not ‘mimicking’)’. 



Some Conclusions and Discussion: According to the authors medical discourses of dementia reinforce ‘a status quo whereby interpersonal interactions are devalued in dementia care, and professional ‘knowledge’ (thereby professional power) is privileged over relationships’. The medical model also frames a person’s problems as being of the ‘individual’. Therefore ‘if distress, loneliness and lack of occupation are framed as an illness, rather than a legitimate response to one’s circumstances, society does not have to change. This fits well with an individualistic, industrial model of society, whereby medical and social care institutions are focussed on economic efficiency’.



However, Intensive Interaction may enable paid caregivers to ‘access person-centred discourses’ (including ‘hopefulness’) and develop related practices aimed at improving a person’s quality of life. However, without wider systemic change in dementia discourse, Intensive Interaction training will be limited in its effectiveness. The adoption of Intensive Interaction requires ‘support from management, organisational structures, and wider society’. 



In conclusion, according to the authors ‘suggestions for future research into dementia care can be orientated around one basic principle: honouring the personhood of people with dementia. This is with a view to providing person-centred, ethical care – by improving communication, enhancing relationships and providing care from a place of collaboration and shared humanity.’ 

},

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pubstate = {published},

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Close

Introduction: According to the authors of this paper, due to ‘the medicalisation of dementia … dehumanising social practices and attitudes are enabled, and reinforced by medical discourses of dementia which have become societal discourse … Within the medical societal discourse, people with dementia are excessively medicated.’ Also, ‘Intensive Interaction assumes that all interaction partners can be meaningfully engaged [and] … can offer an alternative to medicalised discourses (and by proxy, the dehumanising practices enabled by such discourses).’

Study Method: Paid staff from two residential care homes attended an Intensive Interaction training day. These caregivers took part in 2 focus groups before and after the Intensive Interaction training. Transcripts of the focus groups were then analysed using the method of Critical Discourse Analysis, an approach which ‘relates discourse to social power’. The focus group discussion were based on 5 themes identified as missing in medical/societal discourse: ‘personhood’, ‘communication’, ‘embodiment’, ‘reciprocity’ and ‘empathy’.

The Results: Before the Intensive Interaction training carers engaged in ‘medical discourses of loss, non-communication and lack of personhood’. Carers also talked about a lack of resources (time and staff), with job role/hierarchy being important in allowing time (and permission) to interact with residents. “Being with” people with dementia was framed as ‘inactivity’ (‘sitting’, not ‘working’) or ‘a luxury, and therefore separate to paid work within ‘an industrial model’.

After training, caregivers engaged in ‘discourses of communication and personhood’. Intensive Interaction reframed “being with” people as a part of ‘doing work’. Staff viewpoints significantly shifted with carers talking about going ‘into the world’ of the person with dementia, and they also thought that ‘Intensive Interaction would improve relationships’. Intensive Interaction was also seen to ‘legitimise and explain existing relational and creative practices’. However, there were worries that managers might be critical of the approach ‘unless they had training to understand the discourse (e.g. ‘mirroring’ not ‘mimicking’)’.

Some Conclusions and Discussion: According to the authors medical discourses of dementia reinforce ‘a status quo whereby interpersonal interactions are devalued in dementia care, and professional ‘knowledge’ (thereby professional power) is privileged over relationships’. The medical model also frames a person’s problems as being of the ‘individual’. Therefore ‘if distress, loneliness and lack of occupation are framed as an illness, rather than a legitimate response to one’s circumstances, society does not have to change. This fits well with an individualistic, industrial model of society, whereby medical and social care institutions are focussed on economic efficiency’.

However, Intensive Interaction may enable paid caregivers to ‘access person-centred discourses’ (including ‘hopefulness’) and develop related practices aimed at improving a person’s quality of life. However, without wider systemic change in dementia discourse, Intensive Interaction training will be limited in its effectiveness. The adoption of Intensive Interaction requires ‘support from management, organisational structures, and wider society’.

In conclusion, according to the authors ‘suggestions for future research into dementia care can be orientated around one basic principle: honouring the personhood of people with dementia. This is with a view to providing person-centred, ethical care – by improving communication, enhancing relationships and providing care from a place of collaboration and shared humanity.’

Close

Clegg, Judy; Black, Rachael; Smith, Antoin; Brumfitt, Shelagh

Examining the impact of a city-wide intensive interaction staff training program for adults with profound and multiple learning disability: a mixed methods evaluation Journal Article

In: Disability and Rehabilitation , pp. 1-10, 2018, ISSN: 0963-8288.

Abstract | Links | BibTeX

@article{Clegg2018,

title = {Examining the impact of a city-wide intensive interaction staff training program for adults with profound and multiple learning disability: a mixed methods evaluation},

author = { Judy Clegg and Rachael Black and Antoin Smith and Shelagh Brumfitt},

doi = {10.1080/09638288.2018.1495769},

issn = {0963-8288},

year  = {2018},

date = {2018-08-17},

journal = {Disability and Rehabilitation },

pages = {1-10},

abstract = {This study of day service staff focused on answering three questions, these being:



What did staff think about using Intensive Interaction in their daily work with people with PMLD? 

What challenges did staff experience in implementing Intensive Interaction?

What support do staff need to implement Intensive Interaction? 



The city-wide training: 

Seven staff were trained by an independent consultant to become ‘Intensive Interaction coordinators’. These coordinators then delivered Intensive Interaction training to 120 staff working across the city day centres. Staff with a particular interest in the approach were then invited for further training and mentoring by a coordinator who supported them to develop their practice, video their sessions and prepare them to have their work appraised by a panel of other coordinators - if the panel considered their understanding of the approach was sufficient, and they had an aptitude for delivering it, they were signed off as ‘Advanced Practitioners’ (AP). Such APs were then expected to support their colleagues to use Intensive Interaction, as well as use it themselves.  



The Method: 

This study had 2 phases: Phase 1 was a survey looking at the outcomes of Intensive Interaction training on the work practices of 54 staff supporting people with PMLD from day services in a northern UK city.  This survey asked questions about the participant’s role, the length of their employment with people with PMLD, the level of their training, their use of Intensive Interaction, and any barriers they perceived in using the approach. Phase 2 had 29 participants who were interviewed to more fully investigate their experiences and perceptions of using Intensive Interaction. 



The Results: 

The city-wide Intensive Interaction training had a significant impact on the levels of staff knowledge of the approach, their work practices and on their perceptions of people with PMLD. 96% of the participants reported using Intensive Interaction, with 76% also wishing to use the approach with even more people. Using Intensive Interaction was seen to enable staff to build better relationships with their service users, giving them more confidence and greater job satisfaction. However, some challenges in the continued implementation of Intensive Interaction were identified. 

The implementation of Intensive Interaction was reported to be about more than just having adequate and consistent staffing - there was an identified need for a consistent core team of highly skilled and enthusiastic staff (the APs) who are trained in and committed to Intensive Interaction; the ‘Advanced Practitioners’ role was viewed as vital in maintaining staff’s focus on Intensive Interaction across the day centres. Support from managers and dedicated time to reflect on the use of Intensive Interaction were also valued. The completion of Intensive Interaction session and attainment records was also seen as important, as was external support from speech and language therapy services. 



Some implications for future service wide Intensive Interaction interventions:     

Training staff in Intensive Interaction promotes social inclusion for adults with PMLD.

With Intensive Interaction training staff can facilitate and then identify changes in the interactive and communicative behaviours of adults with PMLD.  

Care staff need continued support and training to sustain their use of Intensive Interaction with adults with PMLD.

Services need to reduce the barriers of staffing, management and organisational structures to enable care staff to sustain their use of Intensive Interaction for adults with PMLD. 



In conclusion: 

This study provided robust evidence that a city-wide Intensive Interaction intervention can be effective in increasing both the social inclusion and developmental progression of people with profound and multiple learning disabilities. },

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pubstate = {published},

tppubtype = {article}

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Close

This study of day service staff focused on answering three questions, these being:

What did staff think about using Intensive Interaction in their daily work with people with PMLD?
What challenges did staff experience in implementing Intensive Interaction?
What support do staff need to implement Intensive Interaction?

The city-wide training:
Seven staff were trained by an independent consultant to become ‘Intensive Interaction coordinators’. These coordinators then delivered Intensive Interaction training to 120 staff working across the city day centres. Staff with a particular interest in the approach were then invited for further training and mentoring by a coordinator who supported them to develop their practice, video their sessions and prepare them to have their work appraised by a panel of other coordinators - if the panel considered their understanding of the approach was sufficient, and they had an aptitude for delivering it, they were signed off as ‘Advanced Practitioners’ (AP). Such APs were then expected to support their colleagues to use Intensive Interaction, as well as use it themselves.

The Method:
This study had 2 phases: Phase 1 was a survey looking at the outcomes of Intensive Interaction training on the work practices of 54 staff supporting people with PMLD from day services in a northern UK city. This survey asked questions about the participant’s role, the length of their employment with people with PMLD, the level of their training, their use of Intensive Interaction, and any barriers they perceived in using the approach. Phase 2 had 29 participants who were interviewed to more fully investigate their experiences and perceptions of using Intensive Interaction.

The Results:
The city-wide Intensive Interaction training had a significant impact on the levels of staff knowledge of the approach, their work practices and on their perceptions of people with PMLD. 96% of the participants reported using Intensive Interaction, with 76% also wishing to use the approach with even more people. Using Intensive Interaction was seen to enable staff to build better relationships with their service users, giving them more confidence and greater job satisfaction. However, some challenges in the continued implementation of Intensive Interaction were identified.
The implementation of Intensive Interaction was reported to be about more than just having adequate and consistent staffing - there was an identified need for a consistent core team of highly skilled and enthusiastic staff (the APs) who are trained in and committed to Intensive Interaction; the ‘Advanced Practitioners’ role was viewed as vital in maintaining staff’s focus on Intensive Interaction across the day centres. Support from managers and dedicated time to reflect on the use of Intensive Interaction were also valued. The completion of Intensive Interaction session and attainment records was also seen as important, as was external support from speech and language therapy services.

Some implications for future service wide Intensive Interaction interventions:
Training staff in Intensive Interaction promotes social inclusion for adults with PMLD.
With Intensive Interaction training staff can facilitate and then identify changes in the interactive and communicative behaviours of adults with PMLD.
Care staff need continued support and training to sustain their use of Intensive Interaction with adults with PMLD.
Services need to reduce the barriers of staffing, management and organisational structures to enable care staff to sustain their use of Intensive Interaction for adults with PMLD.

In conclusion:
This study provided robust evidence that a city-wide Intensive Interaction intervention can be effective in increasing both the social inclusion and developmental progression of people with profound and multiple learning disabilities.

Close

Hewett, Dave (Ed.)

The Intensive Interaction Handbook Book

2nd, Sage Publications, 1 Oliver's Yard, 55 City Road, London, EC1Y 1SP, 2018, ISBN: 978-1-5264-2463-1.

Abstract | Links | BibTeX

@book{Hewett2018,

title = {The Intensive Interaction Handbook},

editor = {Dave Hewett},

url = {https://www.intensiveinteraction.org/resources/shop/intensive-interaction-handbook-2nd-edition/},

isbn = {978-1-5264-2463-1},

year  = {2018},

date = {2018-05-01},

publisher = {Sage Publications},

address = {1 Oliver's Yard, 55 City Road, London, EC1Y 1SP},

edition = {2nd},

abstract = {The only guide you need to read on the Intensive Interaction approach returns for its second edition, this time with its founder, Dave Hewett, as the Editor.



The Intensive Interaction approach has spread around the world and has been hugely influential in developing and teaching communication techniques with individuals who have severe learning difficulties and autism.



This straightforward, no-nonsense handbook contains:



- 2 new chapters: The Intensive Interaction Outcomes Reporter; and Autism and Intensive & Intensive Interaction and more able people;



- photo stories demonstrating the approach in practice;



- links to external videos presenting the photo stories in greater depth.



More information on the Intensive Interaction community and approach can be found on dedicated social media pages, and at https://www.intensiveinteraction.org/



Dr. Dave Hewett has been working in the field of special education for 40 years. He was headteacher at Harperbury Hospital School throughout the 1980s, where he and the team worked on the development of Intensive Interaction, producing the first publications and first research on Intensive Interaction, resulting in his doctorate. With Melanie Nind he produced the first Intensive Interaction book in 1994. Since 1990 he has been an independent consultant, continuing to publish extensively and work on the development and dissemination of the approach. Dave also publishes and gives courses on challenging behaviour issues, though as he maintains in the challenging behaviour section of this book, ‘behaviour difficulties are communication difficulties’. It is therefore not a separate topic. He is now director of the Intensive Interaction Institute, travelling and broadcasting the Intensive Interaction message increasingly worldwide.},

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Tee, Abi; Reed, Phil

Controlled study of the impact on child behaviour problems of intensive interaction for children with ASD Journal Article

In: Journal of Research in Special Educational Needs, vol. 17, no. 3, pp. 179–186, 2017, ISSN: 1471-3802.

Abstract | Links | BibTeX

@article{Tee2017,

title = {Controlled study of the impact on child behaviour problems of intensive interaction for children with ASD},

author = {Abi Tee and Phil Reed},

doi = {https://doi.org/10.1111/1471-3802.12376},

issn = {1471-3802},

year  = {2017},

date = {2017-07-01},

urldate = {2017-07-03},

journal = {Journal of Research in Special Educational Needs},

volume = {17},

number = {3},

pages = {179–186},

abstract = {Background: This study explored the effect of a home-based Intensive Interaction (I.I.) programme in reducing behavioural problems in 40 boys with a diagnosis of ASD. The participants’ changes in levels of problem behaviours were compared to a control group who received no intervention. The study also investigated predictors affecting the success of the intervention, including levels of depression in mothers. 



Materials: The Social Communication Questionnaire - SCQ (Rutter et al, 2003) was used to evaluate ASD symptoms. The Strengths and Difficulties Questionnaire - SDQ (Goodman, 1997) was used to evaluate the emotional and behavioural disorders. The Hospital Anxiety & Depression Scale - HADS (Zigmond & Snaith, 1983) was used to assess the presence and severity of anxiety and depression in mothers. 



Interventions: I.I. sessions were administered 5 days a week in the child’s home after school, and lasted 1-2 hours. Tutors were university students who were trained in I.I. Sessions focused on the quality of interactions between the tutor and child; tutors followed the child’s lead by commenting on their actions, joining with them and imitating them. Timing and rhythm were used to increase anticipation and structure to hold the child’s attention and involve turn-taking. Children who were in the control group attended school as normal, and were involved in group and outdoor activities as well as 1-2h period with classroom assistant who addressed their individual needs, but they did not receive I.I.



Procedure: Prior to the intervention, a child psychologist independent from the study assessed the children’s intellectual and language functioning; the I.I. and control groups were matched on these functioning variables as well as by age. In addition, mothers completed the SDQ (assessing the child’s behavioural problems), SCQ (assessing the child’s ASD severity), and HADS (assessing mother’s depression and anxiety). After the six month programme period, mothers rated their children’s behaviour again by completing another SDQ. 



Results: There were no differences in SDQ scores prior to the intervention. The problem behaviour scores decreased in both groups over the 6 months, with the I.I. group’s score only slightly more than the control. A between-subject analysis of covariance revealed no statistically significant effect of intervention.  A Bayes factor was calculated to show a great probability of a null hypothesis. Using the criteria (Jacobson et al, 1984) based on a move between clinical and control sample means, 3 participants in the I.I. intervention group showed a clinically significant reduction in problem behaviour. Additionally, using the same criteria, three participants in the control group showed a clinically significant reduction in problem behaviour. 



Discussion: Although the results suggest that I.I. is not particularly effective in reducing problem behaviour in children with ASD, the literature demonstrates that pupils with problems besides ASD benefit from I.I. (e.g. Kellett, 2003). Future studies should therefore include a wider range of outcome measures (e.g. adaptive and social behaviours) to enhance our understanding of which aspects of child functioning I.I. can impact. 

A number of factors could explain these results; firstly, this study is the first to compare the effectiveness of I.I. to a control group. Secondly, participants in the control group went to a SEN school where staff are well-trained in ASD, thus the effects of employing a home-based intervention may not be noticeable. Finally, receiving 1-2 hours of I.I. for 6 months may not have been long/intensive enough to show a significant advantage over the control group. The results provide insight into the predictors of improvement; baseline level of behaviour problems and level of depression in mother’s both negatively predicted behavioural improvements i.e. less challenging pupils responded best to the programme, and therefore more appropriate targeting of I.I. could benefit some children. In addition, the child’s progress could be mediated by levels of the mother’s depression, highlighting the importance of working closely with parents in the planning of interventions. 

},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

Background: This study explored the effect of a home-based Intensive Interaction (I.I.) programme in reducing behavioural problems in 40 boys with a diagnosis of ASD. The participants’ changes in levels of problem behaviours were compared to a control group who received no intervention. The study also investigated predictors affecting the success of the intervention, including levels of depression in mothers.

Materials: The Social Communication Questionnaire - SCQ (Rutter et al, 2003) was used to evaluate ASD symptoms. The Strengths and Difficulties Questionnaire - SDQ (Goodman, 1997) was used to evaluate the emotional and behavioural disorders. The Hospital Anxiety & Depression Scale - HADS (Zigmond & Snaith, 1983) was used to assess the presence and severity of anxiety and depression in mothers.

Interventions: I.I. sessions were administered 5 days a week in the child’s home after school, and lasted 1-2 hours. Tutors were university students who were trained in I.I. Sessions focused on the quality of interactions between the tutor and child; tutors followed the child’s lead by commenting on their actions, joining with them and imitating them. Timing and rhythm were used to increase anticipation and structure to hold the child’s attention and involve turn-taking. Children who were in the control group attended school as normal, and were involved in group and outdoor activities as well as 1-2h period with classroom assistant who addressed their individual needs, but they did not receive I.I.

Procedure: Prior to the intervention, a child psychologist independent from the study assessed the children’s intellectual and language functioning; the I.I. and control groups were matched on these functioning variables as well as by age. In addition, mothers completed the SDQ (assessing the child’s behavioural problems), SCQ (assessing the child’s ASD severity), and HADS (assessing mother’s depression and anxiety). After the six month programme period, mothers rated their children’s behaviour again by completing another SDQ.

Results: There were no differences in SDQ scores prior to the intervention. The problem behaviour scores decreased in both groups over the 6 months, with the I.I. group’s score only slightly more than the control. A between-subject analysis of covariance revealed no statistically significant effect of intervention. A Bayes factor was calculated to show a great probability of a null hypothesis. Using the criteria (Jacobson et al, 1984) based on a move between clinical and control sample means, 3 participants in the I.I. intervention group showed a clinically significant reduction in problem behaviour. Additionally, using the same criteria, three participants in the control group showed a clinically significant reduction in problem behaviour.

Discussion: Although the results suggest that I.I. is not particularly effective in reducing problem behaviour in children with ASD, the literature demonstrates that pupils with problems besides ASD benefit from I.I. (e.g. Kellett, 2003). Future studies should therefore include a wider range of outcome measures (e.g. adaptive and social behaviours) to enhance our understanding of which aspects of child functioning I.I. can impact.
A number of factors could explain these results; firstly, this study is the first to compare the effectiveness of I.I. to a control group. Secondly, participants in the control group went to a SEN school where staff are well-trained in ASD, thus the effects of employing a home-based intervention may not be noticeable. Finally, receiving 1-2 hours of I.I. for 6 months may not have been long/intensive enough to show a significant advantage over the control group. The results provide insight into the predictors of improvement; baseline level of behaviour problems and level of depression in mother’s both negatively predicted behavioural improvements i.e. less challenging pupils responded best to the programme, and therefore more appropriate targeting of I.I. could benefit some children. In addition, the child’s progress could be mediated by levels of the mother’s depression, highlighting the importance of working closely with parents in the planning of interventions.

Close

Nagra, Maninder K; White, Rose; Appiah, Afua; Rayner, Kelly

Intensive Interaction Training for Paid Carers: ‘Looking, Looking and Find Out When They Want to Relate to You’ Journal Article

In: Journal of Applied Research in Intellectual Disabilities, vol. 30, no. 4, pp. 648-660, 2017.

Abstract | Links | BibTeX

@article{Nagra2017,

title = {Intensive Interaction Training for Paid Carers: ‘Looking, Looking and Find Out When They Want to Relate to You’},

author = { Maninder K Nagra and Rose White and Afua Appiah and Kelly Rayner},

doi = {https://doi.org/10.1111/jar.12259},

year  = {2017},

date = {2017-07-01},

urldate = {2017-06-05},

journal = {Journal of Applied Research in Intellectual Disabilities},

volume = {30},

number = {4},

pages = {648-660},

abstract = {Introduction: the authors of this paper identified Intensive Interaction (II) as a communication approach that is useful when working with people with severe or profound intellectual disabilities who have difficulty with the use and understanding of pre-verbal social communication behaviours. Health and social care providers were identified as offering II training with the goal of improving social communication for clients, with such training resulting in ‘increased use of mirroring movements, vocalisation and contingency responding’.



Materials & Methods: eight carers were recruited to the study two to three years after completing Intensive Interaction training. Data was collected via semi-structured interview asking participants ‘broad questions about the training … the purpose and features of II … [and] how Intensive Interaction is currently used’. The participants were also asked about ‘the training, the approach and the impact this had on the clients and systems’. The 8 transcripts were subjected to Interpretive Phenomenological Analysis as ‘[t]his particular method of analysis aims to understand lived experience and how participants make sense of these experiences’.  



Results: the analysis of participant testimony revealed as significant ‘a master theme of endurance’, a theme that encompassed both ‘the emotional endurance of II for carers and clients, and the practical endurance of its use’. The analysis, illustrated by a wide range of participant quotes, also indicated that: ‘the emotional component of the II approach incorporates two interrelated dominant themes: (i) empowerment and (ii) better understanding with the practical endurance of II incorporating the dominant theme of perceived barriers to implementation’.



Empowerment: as a result of the training the carers commonly expressed a sense of increased confidence when working with their clients. This increased confidence led to ‘an improvement in their relationships, possibly due to carers feeling greater control in tackling challenging situations’. The carers also placed an emphasis on the understanding that clients should be able to ‘let go and do what they would like in a safe environment’. Clients were also thought to socially initiate more often as they were ‘more comfortable in their own homes and around [their] carers’: and perhaps the most crucially, the bond between the carer and the client was believed to be ‘further strengthened as a result of the two-way interaction’.



Realization: the endurance of Intensive Interaction seen in the ‘empowerment of the carers, clients and the relationship between them’, and also in the realization carers had about how care was provided prior to the II training. The carers had though that they were communicating effectively with their clients before the Intensive Interaction programme, but ‘it was only after training that they realised quite what meaningful interaction was’. The carers also clearly expressed how before the training ‘they knew little about their clients, despite having worked with them for as long as three years in one case’. 

The further benefits of II were commonly identified as: ‘better communication, happier clients and an overall positive experience’, with these outcomes being seen as reaffirming the endurance of the approach. Not only was better communication developed, but this ‘two-way process’ was seen to benefit ‘both carers and clients’.



Barriers to implementation: the carers highlighted some difficulties in implementing II within the workplace, with barriers felt to exist at a management level (i.e. a lack of consistent support), and others amongst the carers themselves: e.g. not being able to recall the training (this signifying a ‘sense of decay’ in terms of the learning involved); fear of implementing II ‘inappropriately’; and potential negative reactions from ‘third parties. There was also a perceived need for improved training, refresher or ‘top-up’ courses, on-going support and mentorship from the training facilitators. The training of all carers was also suggested ‘to provide consistency for clients’.  



Discussion: in an extended discussion section the authors state that ‘the overarching impression that emerged from the analysis was the enduring power of II and the importance of two-way interaction’. The paper goes on to discuss related matters that include: ‘Developing relationships’, ‘staying connected’, ‘limitations’, ‘systemic factors’ and ‘ongoing support’ – covering these issues with broad reference to a range literature sources.



Conclusions: in a final short conclusion the authors state that ‘II training supports the practice of a much needed skill … as a way to meet [the] social interaction needs’ of clients with severe or profound learning disabilities. They also call for more research on ‘the effects of organisational characteristics on staff training and practice’ to facilitate the use and uptake of Intensive Interaction.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

Introduction: the authors of this paper identified Intensive Interaction (II) as a communication approach that is useful when working with people with severe or profound intellectual disabilities who have difficulty with the use and understanding of pre-verbal social communication behaviours. Health and social care providers were identified as offering II training with the goal of improving social communication for clients, with such training resulting in ‘increased use of mirroring movements, vocalisation and contingency responding’.

Materials & Methods: eight carers were recruited to the study two to three years after completing Intensive Interaction training. Data was collected via semi-structured interview asking participants ‘broad questions about the training … the purpose and features of II … [and] how Intensive Interaction is currently used’. The participants were also asked about ‘the training, the approach and the impact this had on the clients and systems’. The 8 transcripts were subjected to Interpretive Phenomenological Analysis as ‘[t]his particular method of analysis aims to understand lived experience and how participants make sense of these experiences’.

Results: the analysis of participant testimony revealed as significant ‘a master theme of endurance’, a theme that encompassed both ‘the emotional endurance of II for carers and clients, and the practical endurance of its use’. The analysis, illustrated by a wide range of participant quotes, also indicated that: ‘the emotional component of the II approach incorporates two interrelated dominant themes: (i) empowerment and (ii) better understanding with the practical endurance of II incorporating the dominant theme of perceived barriers to implementation’.

Empowerment: as a result of the training the carers commonly expressed a sense of increased confidence when working with their clients. This increased confidence led to ‘an improvement in their relationships, possibly due to carers feeling greater control in tackling challenging situations’. The carers also placed an emphasis on the understanding that clients should be able to ‘let go and do what they would like in a safe environment’. Clients were also thought to socially initiate more often as they were ‘more comfortable in their own homes and around [their] carers’: and perhaps the most crucially, the bond between the carer and the client was believed to be ‘further strengthened as a result of the two-way interaction’.

Realization: the endurance of Intensive Interaction seen in the ‘empowerment of the carers, clients and the relationship between them’, and also in the realization carers had about how care was provided prior to the II training. The carers had though that they were communicating effectively with their clients before the Intensive Interaction programme, but ‘it was only after training that they realised quite what meaningful interaction was’. The carers also clearly expressed how before the training ‘they knew little about their clients, despite having worked with them for as long as three years in one case’.
The further benefits of II were commonly identified as: ‘better communication, happier clients and an overall positive experience’, with these outcomes being seen as reaffirming the endurance of the approach. Not only was better communication developed, but this ‘two-way process’ was seen to benefit ‘both carers and clients’.

Barriers to implementation: the carers highlighted some difficulties in implementing II within the workplace, with barriers felt to exist at a management level (i.e. a lack of consistent support), and others amongst the carers themselves: e.g. not being able to recall the training (this signifying a ‘sense of decay’ in terms of the learning involved); fear of implementing II ‘inappropriately’; and potential negative reactions from ‘third parties. There was also a perceived need for improved training, refresher or ‘top-up’ courses, on-going support and mentorship from the training facilitators. The training of all carers was also suggested ‘to provide consistency for clients’.

Discussion: in an extended discussion section the authors state that ‘the overarching impression that emerged from the analysis was the enduring power of II and the importance of two-way interaction’. The paper goes on to discuss related matters that include: ‘Developing relationships’, ‘staying connected’, ‘limitations’, ‘systemic factors’ and ‘ongoing support’ – covering these issues with broad reference to a range literature sources.

Conclusions: in a final short conclusion the authors state that ‘II training supports the practice of a much needed skill … as a way to meet [the] social interaction needs’ of clients with severe or profound learning disabilities. They also call for more research on ‘the effects of organisational characteristics on staff training and practice’ to facilitate the use and uptake of Intensive Interaction.

Close

Mourière, Amandine; Scott-Roberts, Sally

Measuring the impact of Intensive Interaction on joint attention and intentional communication: using the FOCAL wheels Journal Article

In: Good Autism Practice , vol. 18, no. 1, pp. 34-45, 2017.

Abstract | Links | BibTeX

@article{Mourière2017,

title = {Measuring the impact of Intensive Interaction on joint attention and intentional communication: using the FOCAL wheels},

author = {Amandine Mourière and Sally Scott-Roberts},

url = {https://www.uffculme.org.uk/attachments/download.asp?file=158&type=pdf},

year  = {2017},

date = {2017-05-09},

journal = {Good Autism Practice },

volume = {18},

number = {1},

pages = {34-45},

abstract = {In this single case study paper, Amandine Mourière, an Intensive Interaction practitioner, shares her work in assessing how Intensive Interaction affects joint attention and intentional communication. She also describes the use of a new FOCAL (Fundamentals of Communication Assessment and Learning) assessment tool.



The aim of this research was to explore the efficacy of Intensive Interaction on the joint attention skills and intentional communication of Jack, a 10-year-old boy with autism, and to review the usefulness of the FOCAL assessment tool - the researcher had already established a bond with Jack and his family by volunteering in a play scheme which he attended. At the time of the study Jack attended a special school and the author worked with Jack at home, after school.

The design of the ‘Fundamentals of Communication Assessment and Learning’ (FOCAL) tool:

The ‘Fundamentals of Communication Assessment and Learning’ tool (FOCAL) used to assess Jack’s communication was designed based on the ‘Sounds of Intents framework’ of Adam Ockelford (2013). This FOCAL tool employed a circular graphic layout (referred to as the ‘FOCAL wheels’) to highlight progress in the 3 separate communication modalities of: 1. Visual and gestural communication, 2. Communication through touch, and 3. Vocal and auditory communication.

Each of the 3 modalities is further divided into 3 domains: reactive, proactive, and interactive. These domains corresponding with the level of awareness in responding to communication (reactive), in causing, creating and controlling communication (proactive), and in participating actively in communication with others (interactive). These 3 domains are divided into 6 segments progressing from ‘the centre, with its focus on the self, outwards, to increasingly wider communities of others’.

Results:



• Clear progress was seen for Jack via the data collated in the FOCAL wheels in the modalities of vocal/auditory and visual/gestural, as a result of the Intensive Interaction intervention.

• Jack’s awareness of the use of eye contact to communicate also progressed over time, in addition to his abilities to initiate and sustain eye contact.

• One parent also reported how Jack sought to communicate by pointing to things in the immediate environment.



From the results, it would appear that Intensive Interaction gave Jack weekly opportunities to practise and further understand the ‘fundamentals of communication’ (Nind and Hewett, 1994), and he was therefore able to become a communicator with more skills than he had at baseline by enhancing his intentional communication. There was also a positive reaction from his school, and Jack started to receive daily sessions of Intensive Interaction as part of his curriculum.



Concluding comments:

Clear progress was seen in Jack’s communicative skills as a result of the Intensive Interaction intervention e.g. in his ability to initiate and sustain social contact, or to acquire a wider range of vocalisations. The results also support the effectiveness of Intensive Interaction with individuals at a pre-verbal level of communication by bringing about the development of their communicative skills.

The FOCAL assessment tool was designed to measure small but essential developmental steps, and to provide an improved understanding of the participant’s abilities and competence as a communicator. The author concludes that the FOCAL tool has the potential to provide a user-friendly method of assessing and recording an individual’s communicative progress.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

In this single case study paper, Amandine Mourière, an Intensive Interaction practitioner, shares her work in assessing how Intensive Interaction affects joint attention and intentional communication. She also describes the use of a new FOCAL (Fundamentals of Communication Assessment and Learning) assessment tool.

The aim of this research was to explore the efficacy of Intensive Interaction on the joint attention skills and intentional communication of Jack, a 10-year-old boy with autism, and to review the usefulness of the FOCAL assessment tool - the researcher had already established a bond with Jack and his family by volunteering in a play scheme which he attended. At the time of the study Jack attended a special school and the author worked with Jack at home, after school.
The design of the ‘Fundamentals of Communication Assessment and Learning’ (FOCAL) tool:
The ‘Fundamentals of Communication Assessment and Learning’ tool (FOCAL) used to assess Jack’s communication was designed based on the ‘Sounds of Intents framework’ of Adam Ockelford (2013). This FOCAL tool employed a circular graphic layout (referred to as the ‘FOCAL wheels’) to highlight progress in the 3 separate communication modalities of: 1. Visual and gestural communication, 2. Communication through touch, and 3. Vocal and auditory communication.
Each of the 3 modalities is further divided into 3 domains: reactive, proactive, and interactive. These domains corresponding with the level of awareness in responding to communication (reactive), in causing, creating and controlling communication (proactive), and in participating actively in communication with others (interactive). These 3 domains are divided into 6 segments progressing from ‘the centre, with its focus on the self, outwards, to increasingly wider communities of others’.
Results:

• Clear progress was seen for Jack via the data collated in the FOCAL wheels in the modalities of vocal/auditory and visual/gestural, as a result of the Intensive Interaction intervention.
• Jack’s awareness of the use of eye contact to communicate also progressed over time, in addition to his abilities to initiate and sustain eye contact.
• One parent also reported how Jack sought to communicate by pointing to things in the immediate environment.

From the results, it would appear that Intensive Interaction gave Jack weekly opportunities to practise and further understand the ‘fundamentals of communication’ (Nind and Hewett, 1994), and he was therefore able to become a communicator with more skills than he had at baseline by enhancing his intentional communication. There was also a positive reaction from his school, and Jack started to receive daily sessions of Intensive Interaction as part of his curriculum.

Concluding comments:
Clear progress was seen in Jack’s communicative skills as a result of the Intensive Interaction intervention e.g. in his ability to initiate and sustain social contact, or to acquire a wider range of vocalisations. The results also support the effectiveness of Intensive Interaction with individuals at a pre-verbal level of communication by bringing about the development of their communicative skills.
The FOCAL assessment tool was designed to measure small but essential developmental steps, and to provide an improved understanding of the participant’s abilities and competence as a communicator. The author concludes that the FOCAL tool has the potential to provide a user-friendly method of assessing and recording an individual’s communicative progress.

Close

Calveley, Julie

Gaining the power of initiation through intensive interaction Journal Article

In: Learning Disability Practice, vol. 20, no. 1, pp. 19-23, 2017.

Abstract | Links | BibTeX

@article{Calveley2017,

title = {Gaining the power of initiation through intensive interaction },

author = {Julie Calveley },

doi = {10.7748/ldp.2017.e1797},

year = {2017},

date = {2017-01-25},

journal = {Learning Disability Practice},

volume = {20},

number = {1},

pages = {19-23},

abstract = {Intensive interaction (I.I.) was introduced to Rosie when she was 15, living at home and cared for by her mother and a team of home carers. Rosie had complex health needs, requiring regular nursing care and frequent hospital admissions. She was non-verbal, physically disabled and visually impaired, and appeared socially passive. At the time the I.I. started Rosie spent all day in bed.

Making a connection: I worked with Rosie, her mum and her carers to develop the use of I.I. - this involved modelling ‘how to do it’. Interactions were filmed so that the video could be used as a teaching tool, and also for progress outcomes to be recorded over a period of time.

As Rosie was visually impaired I needed alternative ways of signalling my social availability, and I used touch, hearing and smell. I always wore the same perfume and to signal my availability, I said her name followed by ‘hello’ and I gently held her hand (gently and slowly at first as her hands were contracted) and monitored her reactions. Signalling my availability to her was not intended to prompt or take the lead, but to send a clear message that ‘you have my full attention’. Having said ‘hello’ and held her hand, I then paused and waited, giving Rosie the chance to take the lead and do something to which I could then respond.

Responsiveness: Early interactions involved contingently responding to the rhythm and sound of Rosie’s breathing. This appeared to promote an awareness in Rosie that I was there for her, as she turned her head towards me and her facial expression indicated that she was intently attending to me. Through frequent repetition of these simple interactions Rosie seemed to become more confident to experiment with a wider range of sounds and movements. She became more intentional in making sounds with her breath, and she also began making vocal sounds with more clarity and frequency. She became more physically active during interactions, moving her arms, hands and upper body. She became more facially expressive and smiled with greater vigour.

When Rosie squeezed my hand, I responded by gently squeezing hers back, or when she stretched her arms out I commented with an ‘aah, big stretch’. Responses were made to all of Rosie’s attempts to vocalise in order to motivate her to find and use her voice more.

Progress: My role was to support Rosie’s mum and the care team to become confident in using I.I., as they were there to provide the repetition needed to make progress. I.I. was carried out as a ‘session’, and also during the care tasks that took up a large part of her day. Our role as I.I. practitioners was to provide a responsive social environment supportive of participation, exploration, experimentation and play.

Conclusion: This article shows how I.I. enabled Rosie’s mum and carers to connect with her socially, emotionally and psychologically. This enabled Rosie to be an active participant during the interactions, and motivated her to want to communicate more.

Gradually, with Rosie learning that what she could do got a response and therefore was seen to have value, she gained the power of social initiation and a greater ability to feel that she was a purposeful and successful communicator.

},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

Intensive interaction (I.I.) was introduced to Rosie when she was 15, living at home and cared for by her mother and a team of home carers. Rosie had complex health needs, requiring regular nursing care and frequent hospital admissions. She was non-verbal, physically disabled and visually impaired, and appeared socially passive. At the time the I.I. started Rosie spent all day in bed.

Making a connection: I worked with Rosie, her mum and her carers to develop the use of I.I. - this involved modelling ‘how to do it’. Interactions were filmed so that the video could be used as a teaching tool, and also for progress outcomes to be recorded over a period of time.

As Rosie was visually impaired I needed alternative ways of signalling my social availability, and I used touch, hearing and smell. I always wore the same perfume and to signal my availability, I said her name followed by ‘hello’ and I gently held her hand (gently and slowly at first as her hands were contracted) and monitored her reactions. Signalling my availability to her was not intended to prompt or take the lead, but to send a clear message that ‘you have my full attention’. Having said ‘hello’ and held her hand, I then paused and waited, giving Rosie the chance to take the lead and do something to which I could then respond.

Responsiveness: Early interactions involved contingently responding to the rhythm and sound of Rosie’s breathing. This appeared to promote an awareness in Rosie that I was there for her, as she turned her head towards me and her facial expression indicated that she was intently attending to me. Through frequent repetition of these simple interactions Rosie seemed to become more confident to experiment with a wider range of sounds and movements. She became more intentional in making sounds with her breath, and she also began making vocal sounds with more clarity and frequency. She became more physically active during interactions, moving her arms, hands and upper body. She became more facially expressive and smiled with greater vigour.
When Rosie squeezed my hand, I responded by gently squeezing hers back, or when she stretched her arms out I commented with an ‘aah, big stretch’. Responses were made to all of Rosie’s attempts to vocalise in order to motivate her to find and use her voice more.

Progress: My role was to support Rosie’s mum and the care team to become confident in using I.I., as they were there to provide the repetition needed to make progress. I.I. was carried out as a ‘session’, and also during the care tasks that took up a large part of her day. Our role as I.I. practitioners was to provide a responsive social environment supportive of participation, exploration, experimentation and play.

Conclusion: This article shows how I.I. enabled Rosie’s mum and carers to connect with her socially, emotionally and psychologically. This enabled Rosie to be an active participant during the interactions, and motivated her to want to communicate more.
Gradually, with Rosie learning that what she could do got a response and therefore was seen to have value, she gained the power of social initiation and a greater ability to feel that she was a purposeful and successful communicator.

Close

Weedle, Suzanna

The use of intensive interaction with people with severe-profound intellectual disability Journal Article

In: Learning Disability Practice, vol. 19, no. 9, pp. 27-34, 2016.

Abstract | Links | BibTeX

@article{Weedle2016,

title = {The use of intensive interaction with people with severe-profound intellectual disability },

author = {Suzanna Weedle},

doi = {10.7748/ldp.2016.e1780},

year = {2016},

date = {2016-10-26},

journal = {Learning Disability Practice},

volume = {19},

number = {9},

pages = {27-34},

abstract = {This paper reviewed the academic and research literature focusing on studies of Intensive Interaction with people with a severe-profound intellectual disability. The literature search produced 18 relevant peer-reviewed papers (6 quantitative, 6 mixed methods and 4 qualitative) 16 from the UK, 1 from Australia and 1 from a study in Romania. All the studies had small sample sizes, the largest being 18.

A thematic analysis of the papers was carried out, and four main themes emerged: social engagement; the effect of Intensive Interaction on people with intellectual disability; the effect of Intensive Interaction on practitioners; barriers to implementation.

Social engagement: this theme focused on an individual’s social engagement with the person implementing the intervention. The literature suggested that Intensive Interaction is most suitable for people who are in some way socially isolated or withdrawn, this being because Intensive Interaction is effective in enhancing social engagement. It was found across a number of papers that there was a clear increase in sociability compared with measurements at ‘baseline’. The studies used behavioural indicators to demonstrate increased social engagement; with these indicators including eye contact, engagement in mutual activity, body orientation, and proximity to partner, etc.

Four studies measured progress in communication development. These studies found that participants initiated communications more effectively. There was also an increase in vocalisations during sessions, which could be viewed as increased attempts at communication. Following Intensive Interaction there was also a reduction in self-stimulation and active avoidant behaviours, and also behaviours such as hand biting, rocking and head banging, which were considered to be barriers to social interaction.

Effects on people with intellectual disability: taking part in Intensive Interaction was seen as enjoyable and satisfying for clients, and as a more proactive and empowering approach. The effects reported for people with intellectual disability included increased client-initiated social activity, increased smiling, emotional valence, and a greater sense of well-being. There was also evidence of a decrease in distress i.e. reduced levels distress and self-harm among children. Similarly, it was seen that the person with an intellectual disability developed a greater ‘sense of self’ by learning that through Intensive Interaction they could affect their own environment.

Effects on practitioners: the importance of recognising that Intensive Interaction involves both the client and practitioner in a mutually communicative relationship was noted. Staff experienced increased job satisfaction due to an enhanced connection with the person they were supporting. Also the staff team felt an increased sense of team cohesion and empowerment, with staff feeling more capable of demonstrating that they cared, noting they felt Intensive Interaction gave them more ‘permission’ to touch or spend time with their client.

It was also noted that there was a greater sense of connection between staff and clients, with 32.5% finding relationship development a significant benefit of Intensive Interaction. This relationship development was evidenced in increased reciprocal interactions with clients, which also increased the motivation of staff.

There were however some practitioners’ concerns, particularly male practitioners being worried about issues of touch with female service users, including concerns about sexual assault allegations. This left some staff members unwilling to work physically close to clients, noting that it made them feel uncomfortable.

Barriers to implementing: there were reports of some environmental constraints which made the use of Intensive Interaction more challenging i.e. time constraints, staff shortages, and pressurised environments. Some practitioners were reported as having initial doubts about Intensive Interaction because they did not anticipate the positive outcomes: however, after they witnessed positive effects the resistance was overcome.

Conclusion: this review provides an improved understanding of the benefits and limitations of using Intensive Interaction. Overall Intensive Interaction was seen to increase a clients’ social engagement, strengthen their relationships and positively affect their overall well-being. However there are still some barriers, particularly concerning initial resistance from staff teams.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

This paper reviewed the academic and research literature focusing on studies of Intensive Interaction with people with a severe-profound intellectual disability. The literature search produced 18 relevant peer-reviewed papers (6 quantitative, 6 mixed methods and 4 qualitative) 16 from the UK, 1 from Australia and 1 from a study in Romania. All the studies had small sample sizes, the largest being 18.

A thematic analysis of the papers was carried out, and four main themes emerged: social engagement; the effect of Intensive Interaction on people with intellectual disability; the effect of Intensive Interaction on practitioners; barriers to implementation.

Social engagement: this theme focused on an individual’s social engagement with the person implementing the intervention. The literature suggested that Intensive Interaction is most suitable for people who are in some way socially isolated or withdrawn, this being because Intensive Interaction is effective in enhancing social engagement. It was found across a number of papers that there was a clear increase in sociability compared with measurements at ‘baseline’. The studies used behavioural indicators to demonstrate increased social engagement; with these indicators including eye contact, engagement in mutual activity, body orientation, and proximity to partner, etc.

Four studies measured progress in communication development. These studies found that participants initiated communications more effectively. There was also an increase in vocalisations during sessions, which could be viewed as increased attempts at communication. Following Intensive Interaction there was also a reduction in self-stimulation and active avoidant behaviours, and also behaviours such as hand biting, rocking and head banging, which were considered to be barriers to social interaction.

Effects on people with intellectual disability: taking part in Intensive Interaction was seen as enjoyable and satisfying for clients, and as a more proactive and empowering approach. The effects reported for people with intellectual disability included increased client-initiated social activity, increased smiling, emotional valence, and a greater sense of well-being. There was also evidence of a decrease in distress i.e. reduced levels distress and self-harm among children. Similarly, it was seen that the person with an intellectual disability developed a greater ‘sense of self’ by learning that through Intensive Interaction they could affect their own environment.

Effects on practitioners: the importance of recognising that Intensive Interaction involves both the client and practitioner in a mutually communicative relationship was noted. Staff experienced increased job satisfaction due to an enhanced connection with the person they were supporting. Also the staff team felt an increased sense of team cohesion and empowerment, with staff feeling more capable of demonstrating that they cared, noting they felt Intensive Interaction gave them more ‘permission’ to touch or spend time with their client.

It was also noted that there was a greater sense of connection between staff and clients, with 32.5% finding relationship development a significant benefit of Intensive Interaction. This relationship development was evidenced in increased reciprocal interactions with clients, which also increased the motivation of staff.

There were however some practitioners’ concerns, particularly male practitioners being worried about issues of touch with female service users, including concerns about sexual assault allegations. This left some staff members unwilling to work physically close to clients, noting that it made them feel uncomfortable.

Barriers to implementing: there were reports of some environmental constraints which made the use of Intensive Interaction more challenging i.e. time constraints, staff shortages, and pressurised environments. Some practitioners were reported as having initial doubts about Intensive Interaction because they did not anticipate the positive outcomes: however, after they witnessed positive effects the resistance was overcome.

Conclusion: this review provides an improved understanding of the benefits and limitations of using Intensive Interaction. Overall Intensive Interaction was seen to increase a clients’ social engagement, strengthen their relationships and positively affect their overall well-being. However there are still some barriers, particularly concerning initial resistance from staff teams.

Close

Rayner, Kelly; Bradley, Samantha; Johnson, Gemma; Mrozik, Jennifer H; Appiah, Afua; Nagra, Maninder K

Teaching intensive interaction to paid carers: using the ‘communities of practice’ model to inform training Journal Article

In: British Journal of Learning Disabilities, vol. 44, no. 1, pp. 63-70, 2016.

Abstract | Links | BibTeX

@article{Rayner2016,

title = {Teaching intensive interaction to paid carers: using the ‘communities of practice’ model to inform training},

author = {Kelly Rayner and Samantha Bradley and Gemma Johnson and Jennifer H Mrozik and Afua Appiah and Maninder K Nagra },

doi = {10.1111/bld.12111},

year = {2016},

date = {2016-03-01},

urldate = {2016-01-22},

journal = {British Journal of Learning Disabilities},

volume = {44},

number = {1},

pages = {63-70},

abstract = {Introduction: The acquisition of skills through observation at the periphery before moving into active participation suggests learning is ‘not a process of … internalisation of knowledge by individuals, but as a process of becoming a member of a sustained community of practice’ (Lave, 1991). This ‘communication of practice’ approach was applied to a six-week I.I. training programme for carers which comprised three workshops utilising didactic teaching, reflective group discussion, peer support and formal supervision of the carers by their managers, who in turn received supervision from workshop facilitators. This study evaluated the training programme by identifying key themes emerging from the participants’ experience of the programme and their subsequent use of the techniques.

Method: Participants were two carers and one home manager (aged 48, 44 and 25 years) who had no formal training in I.I.. The participants were interviewed within six months of training, the data collected through semi-structured interviews asking broad questions about the training e.g. the purpose and features of I.I., experiences of the training and practice, support and supervision needs and the presentation of the clients and colleagues. The transcripts were subjected to Interpretative Phenomenological Analysis - a qualitative research approach endeavouring to examine how people make sense of their life experiences.

Results: The analysis revealed a master theme of ‘insight’ which covered carer and client progress, change and development. 3 inter-related dominant themes also emerged: (i) investment, (ii) transformation, and (iii) challenges.

i) Investment: The staff interviewed expressed feelings of personal development from practising I.I.. Staff suggested that they now fully responded to individual needs, and so addressed more than just the basics: ‘The training at times it (...) it made it I think it makes you feel quite emotional (...)’. Staff felt they were gaining in both competence and confidence: ‘the more of the sessions I went on the more fluid it became, the more easier, the less inhibited I felt...’.

Staff members found it difficult to put what they were experiencing into words, and suggested that in order to understand the change in their practice one would have to actually see it: ‘... all I can liken it t’ (...) the light bulb goes on and the communication come out (...) you can’t put it into words you’ve got to be there’.

ii) Transformation: the Staff described a transformation in clients, suggesting that I.I. had brought clients to life: ‘It’s just amazing how it just the conversation’s getting more and a lot of their vocabulary is getting more and more each week’. There was also an evident shift in the attitudes of the participants towards the training: ‘initially when I saw the timetable I thought “well that’s not very much, that would be great just an hour or two” but it was an intense hour or two that you could get a lot out of and learn a lot from’

Participants also shifted in their sense of what makes an effective intervention, and perhaps adjusted their expectations of what is a good clinical outcome ‘that does seem to calm him down, it might only be for a few seconds but it works’. There was also evidence that I.I. allowed care staff to think in a more person centred way about choice and the expression of wants. It was noted staff also experienced higher levels of job satisfaction.

Supervision was valued by the staff; it raised self-confidence and helped staff to develop connections with clients. A consistency and unity within the working environment was highly evident: staff were intent on fostering productive relationships with colleagues and clients alike. Staff also expressed a need for all staff to be trained in I.I.

iii) Challenges: Staff evidenced initial resistance as they could not at first envision the benefits of I.I., however they soon came around after seeing the results for themselves. Like clients, it appeared staff had also experienced things that affected them profoundly: ‘I just thought ... I just couldn’t believe what I was seeing ... I’ve worked with this gentleman nearly four years and I have never seen him do that’

Discussion: The overall impression given is the enormity of the positive experiences of carers using I.I. and the profound shift in beliefs, progress and development. This study suggests that effective communication is crucial for the development of a person’s identity, for increased social inclusion and improved quality of life. In this study staff found relationships more meaningful and held a deeper understanding of their clients, their co-workers and themselves. Staff gained a new found knowledge of clients’ needs and a new connection with them.

The analysis demonstrated how I.I. can lead to a higher quality of person-centred care, promoting empathic communication, improving the individual’s wellbeing, self-worth and quality of life. This implies that if I.I. training is accessible to staff in various care settings, staff will develop improved insight and a deeper relations with co-workers and clients, creating a potentially more resilient workforce.

The analysis suggested workers felt nurtured by supportive supervision, evidencing how a ‘community of practice’ can act as a protective factor against the potential for initiative decay. The findings also suggest that systemic practices derived from I.I. could foster a working culture which promotes respect and inclusion for clients.

The wider implications of the study include the ability to transform procedures and attitudes in staff regardless of length of time in service or how regimented a service is. The profound effect on the staff members can be seen in the shift in the language they use to describe the approach, their use of it and the results they have seen.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

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Introduction: The acquisition of skills through observation at the periphery before moving into active participation suggests learning is ‘not a process of … internalisation of knowledge by individuals, but as a process of becoming a member of a sustained community of practice’ (Lave, 1991). This ‘communication of practice’ approach was applied to a six-week I.I. training programme for carers which comprised three workshops utilising didactic teaching, reflective group discussion, peer support and formal supervision of the carers by their managers, who in turn received supervision from workshop facilitators. This study evaluated the training programme by identifying key themes emerging from the participants’ experience of the programme and their subsequent use of the techniques.

Method: Participants were two carers and one home manager (aged 48, 44 and 25 years) who had no formal training in I.I.. The participants were interviewed within six months of training, the data collected through semi-structured interviews asking broad questions about the training e.g. the purpose and features of I.I., experiences of the training and practice, support and supervision needs and the presentation of the clients and colleagues. The transcripts were subjected to Interpretative Phenomenological Analysis - a qualitative research approach endeavouring to examine how people make sense of their life experiences.

Results: The analysis revealed a master theme of ‘insight’ which covered carer and client progress, change and development. 3 inter-related dominant themes also emerged: (i) investment, (ii) transformation, and (iii) challenges.
i) Investment: The staff interviewed expressed feelings of personal development from practising I.I.. Staff suggested that they now fully responded to individual needs, and so addressed more than just the basics: ‘The training at times it (...) it made it I think it makes you feel quite emotional (...)’. Staff felt they were gaining in both competence and confidence: ‘the more of the sessions I went on the more fluid it became, the more easier, the less inhibited I felt...’.
Staff members found it difficult to put what they were experiencing into words, and suggested that in order to understand the change in their practice one would have to actually see it: ‘... all I can liken it t’ (...) the light bulb goes on and the communication come out (...) you can’t put it into words you’ve got to be there’.
ii) Transformation: the Staff described a transformation in clients, suggesting that I.I. had brought clients to life: ‘It’s just amazing how it just the conversation’s getting more and a lot of their vocabulary is getting more and more each week’. There was also an evident shift in the attitudes of the participants towards the training: ‘initially when I saw the timetable I thought “well that’s not very much, that would be great just an hour or two” but it was an intense hour or two that you could get a lot out of and learn a lot from’
Participants also shifted in their sense of what makes an effective intervention, and perhaps adjusted their expectations of what is a good clinical outcome ‘that does seem to calm him down, it might only be for a few seconds but it works’. There was also evidence that I.I. allowed care staff to think in a more person centred way about choice and the expression of wants. It was noted staff also experienced higher levels of job satisfaction.
Supervision was valued by the staff; it raised self-confidence and helped staff to develop connections with clients. A consistency and unity within the working environment was highly evident: staff were intent on fostering productive relationships with colleagues and clients alike. Staff also expressed a need for all staff to be trained in I.I.
iii) Challenges: Staff evidenced initial resistance as they could not at first envision the benefits of I.I., however they soon came around after seeing the results for themselves. Like clients, it appeared staff had also experienced things that affected them profoundly: ‘I just thought ... I just couldn’t believe what I was seeing ... I’ve worked with this gentleman nearly four years and I have never seen him do that’

Discussion: The overall impression given is the enormity of the positive experiences of carers using I.I. and the profound shift in beliefs, progress and development. This study suggests that effective communication is crucial for the development of a person’s identity, for increased social inclusion and improved quality of life. In this study staff found relationships more meaningful and held a deeper understanding of their clients, their co-workers and themselves. Staff gained a new found knowledge of clients’ needs and a new connection with them.

The analysis demonstrated how I.I. can lead to a higher quality of person-centred care, promoting empathic communication, improving the individual’s wellbeing, self-worth and quality of life. This implies that if I.I. training is accessible to staff in various care settings, staff will develop improved insight and a deeper relations with co-workers and clients, creating a potentially more resilient workforce.

The analysis suggested workers felt nurtured by supportive supervision, evidencing how a ‘community of practice’ can act as a protective factor against the potential for initiative decay. The findings also suggest that systemic practices derived from I.I. could foster a working culture which promotes respect and inclusion for clients.

The wider implications of the study include the ability to transform procedures and attitudes in staff regardless of length of time in service or how regimented a service is. The profound effect on the staff members can be seen in the shift in the language they use to describe the approach, their use of it and the results they have seen.

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Hutchinson, Nick; Bodicoat, Anna

The Effectiveness of Intensive Interaction, A Systematic Literature Review Journal Article

In: Journal of Applied Research in Intellectual Disabilities, vol. 28, no. 6, pp. 437-454, 2015.

Abstract | Links | BibTeX

@article{Hutchinson2015,

title = {The Effectiveness of Intensive Interaction, A Systematic Literature Review},

author = {Nick Hutchinson and Anna Bodicoat},

doi = { https://doi.org/10.1111/jar.12138},

year = {2015},

date = {2015-11-01},

urldate = {2015-10-02},

journal = {Journal of Applied Research in Intellectual Disabilities},

volume = {28},

number = {6},

pages = {437-454},

abstract = {This paper looked at 15 quantitative and 3 qualitative peer-reviewed papers which examined the efficacy of Intensive Interaction (I.I.) with participants of different ages in both educational and residential settings:

In Nind’s 1996 study, a multiple-baseline study with 6 adult participants, there was some evidence that all participants gained in their sociability and communication, although according to the authors these improvements were not always directly concurrent with the start of the I.I., casting some doubt as to the cause. However, the authors also state that Nind gave persuasive arguments for the link i.e. that the participants had long-standing communicative difficulties, many behaviours occurred for the first time after the I.I. began, and no other events were know to be concurrent with the improvements.

The various studies by Kellett (2000/3/4/5) were said to have unstable baselines and variability in the scores coded, thus limiting the conclusions that could be drawn. In Barber’s study (2008) the extended baseline to post-I.I. measurement cast doubt on the cause of the improved sociability (and data from only 3 of 11 students was given). Leaning & Watson (2006) reported data from only 3 of 5 participants, although these did show improvements, but the missing data again raised bias issues. Samuel et al. (2008) reported an increase in social behaviour, but these increases were small (<5% were classed as a ‘noticeable increase’).

Other papers also used video, with Zeedyk simplifying the analysis, thus making it easier to see that all participants increased on their levels of ‘Engagement’ with I.I. The use of an ABA methodological design by Argyropoulou & Papoudi (2012) provided strong support for I.I. being responsible for increasing the amount of initiations from the child participant in their study. In all three of the qualitative papers reviewed, sociability was perceived to be enhanced by I.I.; however, validity was limited in two studies by a lack of clear methodology.

According to the authors the conclusions that can reasonably be drawn from the evidence did not reflect the positive anecdotal evidence reported by practitioners of I.I.: however, as the authors point out, in a systematic review anecdotal reports are considered ‘insufficient evidence’, and books and dissertations are excluded due to the lack of peer reviewing.

Conclusions: according to the authors ‘any conclusions [about I.I.] should be cautious due to findings being limited by unstable baselines, AB designs and small improvements. However, all papers reviewed found at least some increase in sociability. The research so far could indicate that I.I. may help to develop communicative abilities; however, the limitations of the studies prevent firm conclusions being drawn’.

The limited empirical evidence did not, in the authors’ opinion, support the powerful claims made by the people who were conducting the I.I. However they say that this may be due to the difficulty in conducting good quality, methodologically and ethically sound research with people with intellectual disabilities. The authors also commented that the use of video coding of social behaviours in relation to an approach like I.I. seemed potentially reductionist, and that other methods of assessment might be more appropriate

Summary: Because the studies had clear limitations, the authors stated that they could not firmly conclude whether I.I. is likely to be a helpful for people with learning disabilities and/or autism. But, based on the studies examined in this paper, the authors positively offered several ways of increasing the effectiveness of the approach. These include a team based approach and support, so that in-depth exploration of difficult issues can be a component of any I.I..

The authors also stated that: ‘to provide I.I. with the evidence base it lacks at present, the methodological quality of both quantitative and qualitative studies needs to be examined closely, and research, once finished should be submitted to peer-reviewed journals’.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

Close

This paper looked at 15 quantitative and 3 qualitative peer-reviewed papers which examined the efficacy of Intensive Interaction (I.I.) with participants of different ages in both educational and residential settings:

In Nind’s 1996 study, a multiple-baseline study with 6 adult participants, there was some evidence that all participants gained in their sociability and communication, although according to the authors these improvements were not always directly concurrent with the start of the I.I., casting some doubt as to the cause. However, the authors also state that Nind gave persuasive arguments for the link i.e. that the participants had long-standing communicative difficulties, many behaviours occurred for the first time after the I.I. began, and no other events were know to be concurrent with the improvements.

The various studies by Kellett (2000/3/4/5) were said to have unstable baselines and variability in the scores coded, thus limiting the conclusions that could be drawn. In Barber’s study (2008) the extended baseline to post-I.I. measurement cast doubt on the cause of the improved sociability (and data from only 3 of 11 students was given). Leaning & Watson (2006) reported data from only 3 of 5 participants, although these did show improvements, but the missing data again raised bias issues. Samuel et al. (2008) reported an increase in social behaviour, but these increases were small (<5% were classed as a ‘noticeable increase’).

Other papers also used video, with Zeedyk simplifying the analysis, thus making it easier to see that all participants increased on their levels of ‘Engagement’ with I.I. The use of an ABA methodological design by Argyropoulou & Papoudi (2012) provided strong support for I.I. being responsible for increasing the amount of initiations from the child participant in their study. In all three of the qualitative papers reviewed, sociability was perceived to be enhanced by I.I.; however, validity was limited in two studies by a lack of clear methodology.

According to the authors the conclusions that can reasonably be drawn from the evidence did not reflect the positive anecdotal evidence reported by practitioners of I.I.: however, as the authors point out, in a systematic review anecdotal reports are considered ‘insufficient evidence’, and books and dissertations are excluded due to the lack of peer reviewing.

Conclusions: according to the authors ‘any conclusions [about I.I.] should be cautious due to findings being limited by unstable baselines, AB designs and small improvements. However, all papers reviewed found at least some increase in sociability. The research so far could indicate that I.I. may help to develop communicative abilities; however, the limitations of the studies prevent firm conclusions being drawn’.

The limited empirical evidence did not, in the authors’ opinion, support the powerful claims made by the people who were conducting the I.I. However they say that this may be due to the difficulty in conducting good quality, methodologically and ethically sound research with people with intellectual disabilities. The authors also commented that the use of video coding of social behaviours in relation to an approach like I.I. seemed potentially reductionist, and that other methods of assessment might be more appropriate

Summary: Because the studies had clear limitations, the authors stated that they could not firmly conclude whether I.I. is likely to be a helpful for people with learning disabilities and/or autism. But, based on the studies examined in this paper, the authors positively offered several ways of increasing the effectiveness of the approach. These include a team based approach and support, so that in-depth exploration of difficult issues can be a component of any I.I..

The authors also stated that: ‘to provide I.I. with the evidence base it lacks at present, the methodological quality of both quantitative and qualitative studies needs to be examined closely, and research, once finished should be submitted to peer-reviewed journals’.

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