Intensive Interaction Institute - Publications and Bibliography

@article{McKim2021,

title = {The use of Intensive Interaction within a Positive Behavioural Support framework},

author = {Jules McKim and Judith Samuel },

url = {https://onlinelibrary.wiley.com/doi/10.1111/bld.12367},

doi = {https://doi.org/10.1111/bld.12367},

issn = {1111-1236},

year  = {2021},

date = {2021-01-22},

journal = {British Journal of Learning Disabilities},

volume = {49},

number = {2},

pages = {129-137},

abstract = {1.1 Background

Positive Behavioural Support (PBS) provides an overarching framework for supporting quality-of-life improvements for people who use challenging behaviour. Rapport, or the lack of it, is well understood as a setting factor for some challenging behaviours. Intensive Interaction is an approach that, among other possible outcomes, can develop rapport and feelings of safety, security and connection.

1.2 Method

Within an NHS Trust, the Intensive Interaction Service works in partnership with the Intensive Support Team. We present case descriptions of people who used challenging behaviour and received Intensive Interaction support. Changes are described using staff and family interview data. The Intensive Interaction techniques that helped develop rapport at each PBS phase are described.

1.3 Results

Intensive Interaction was used in all PBS phases. It played a role in preventing placement breakdown for one individual.

1.4 Conclusion

Intensive Interaction should be considered at initial assessment within PBS so that immediate and important improvements can be made to the person's social and communication experience. It is hoped that Intensive Support Services and all PBS practitioners will use it.},

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@article{Shearer2020,

title = {Intensive interaction: an evaluation of two different recording formats},

author = {Katherine Shearer and Charlotte Parkhouse },

url = {https://www.ingentaconnect.com/contentone/bild/gap/2020/00000021/00000002/art00004},

issn = {1466-2973 Print; 2046-5521 Online},

year  = {2020},

date = {2020-10-01},

journal = {Good Autism Practice },

volume = {21},

number = {2},

pages = {23-32},

abstract = {Intensive interaction is an approach developed in the UK in the 1990s for children and adults whom staff and parents have often found difficult to engage. The focus is on following the person's lead and in so doing to build a relationship and establish engagement and develop communication. In this study, the authors sought to ascertain the value of two different recording methods within a special school. Twenty staff were trained in the approach, ten of whom used a diary format and the other ten used the Engagement Profile (Carpenter and Egerton, 2011). The pros and cons of each are discussed in addition to considering the practical issues of using Intensive Interaction within a school setting. A very important point raised is that regular discussions held between staff on their practice and how they might enhance this, were extremely valuable, irrespective of the recording format and approach used.},

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@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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@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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@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. 

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@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.},

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@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.},

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@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. 

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@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.},

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@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.},

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@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’.},

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@article{Lloyd2015,

title = {Intensive Interaction in the mainstream classroom: evaluating staff attitudes towards an inclusive socio-communicative intervention },

author = {Eleanor M Lloyd},

url = {https://www.ingentaconnect.com/content/bild/gap/2015/00000016/00000002/art00008},

issn = {1466-2973},

year  = {2015},

date = {2015-10-02},

journal = {Good Autism Practice},

volume = {16},

number = {2},

pages = {49-68},

abstract = {Introduction: The inclusion of children with autism in mainstream schools is an important area for practice and research. Unfortunately current national strategies require children to be taught more often in whole class groupings, this being particularly challenging for pupils with autism. This project investigated the possibility of achieving inclusion via daily 15 to 20 minute sessions of a classroom-based activity called ‘Communiplay’ which was based on Intensive Interaction. However, Communiplay differed from ‘traditional’ Intensive Interaction in that it took place in small groups and was structured around play with a LEGO construction set: this being seen as inherently rewarding for the pupils with autism, whilst also promoting child initiation and adult imitation in mutually enjoyable interactions. 



The project involved 6 classes (of <30 pupils aged 5-7 years) in an inner-city mainstream school. The classes included one or more pupils with a language or socio-communicative disorder. The staff teams were a teacher and two Teaching Assistants (TAs), who had a 70 minute training session on Intensive Interaction and Communiplay. Three Communiplay groups were formed in each class, consisting of: one child with a diagnosis of SEN (the ‘focus pupil’ who was partnered with the adult for Intensive Interaction) and two other pupils matched as play partners for each other. The teacher and TAs participated in one Communiplay group each day, and in the other groups once or twice a week. 



Research design: This project combined qualitative elements with a quasi-experimental design, and collected data on the views of the teachers and TAs via: a Relationship Interaction Assessment, a Team Evaluation Form, an Everyday Communiplay Log, a Mid-Invention Review, an Evaluation Focus Group, and a Structured Observation Schedule. 



Findings: the findings of this study indicated ‘that Communiplay may be effective in strengthening positive staff-pupil relationships and the amount of pupil initiated interaction with staff’. Also the author states that ‘staff-pupil interactions in the class as a whole may have been positively influenced by the intervention, even though the majority of children did not participate in a Communiplay trio’. 



10 elements were seen by staff as relevant to the quality of pupils’ interactivity. These were: 

1. An expectation of peer conversation 

2. Staff being approachable and interested 

3. A relaxed pace to arriving in class 

4. Staff deliberately giving attention to focus pupils 

5. Staff sitting at the child’s level and children interacting while standing 

6. Pupils having freedom to choose from a range of activities 

7. Mutual laughter 

8. Informal physical contact conveying connection 

9. Extended interactions 

10. Staff being available to relate, rather than being busy with tasks.



The study also found that most staff were comfortable doing Communiplay in the classroom, although some did find the practice uncomfortable. However, the staff also found it impractical to fit 3 sessions of Communiplay into their daily schedules, and that the single training session on I.I. proved insufficient to achieve consistency of practice. The difficulty teachers had fitting Communiplay into the timetable apparently indicated an unwillingness to prioritise it over other, more instructional, teaching tasks.   



In conclusion: despite a number of acknowledged limitations to this study, the findings confirm the difficultly a class teacher, under pressure to deliver the National Curriculum, has in making I.I. available in a mainstream classroom. According to the author, radical shifts are needed in staff preparedness, deployment and practice. Also a more individualised application of the National Curriculum is necessary to enable pupils with autism to develop their socio-communicative abilities.  



The value of this study is in documenting the use of Intensive Interaction within mainstream classrooms. This intervention created intrinsically motivating and inclusive learning environments that contributed to the social development and well-being of children with autism and their peers with SEN. In terms of inclusion, creating communication enabling classrooms that focus on the responsiveness of staff is likely to yield the most benefits. 

},

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@article{Berry2014,

title = {Clinical Psychologists' Views of Intensive Interaction as an Intervention in Learning Disability Services},

author = {Ruth Berry and Graham Firth },

doi = {https://doi.org/10.1002/cpp.1846},

issn = {1002-1846},

year  = {2014},

date = {2014-09-01},

urldate = {2014-10-03},

journal = {Clinical Psychology & Psychotherapy},

volume = {21},

number = {5},

pages = {403-410},

abstract = {Some Background

This explored clinical psychologists’ views of Intensive Interaction as an intervention in learning disability services in terms of its theoretical underpinning and empirical support. It was also hoped that the study might illuminate significant issues influencing clinical psychologists’ adoption of the approach, including the participants’ thinking about the relevance of established psychological models and theories.



Overview of the Study 

This qualitative study involved interviews with eight clinical psychologists from across the UK who were known to be working with adult clients with severe or profound intellectual disabilities, and to be using or advocating Intensive Interaction. The study utilised a grounded theory approach to analyse and categorise the resulting data.



Results & Discussion

All the participants were asked whether they saw Intensive Interaction as being concordant with any established psychological theories and were given specific exemplars. The models that were spoken about were attachment theory, developmental theory, Person-Centred Therapy (PCT), social role valorisation/normalisation, behaviourism, Ephraim’s ‘augmented mothering’, attribution theory, sensory integration, psychoanalytic models, social constructionism and humanistic psychology. 



Of the six participants who spoke about attachment theory, all described Intensive Interaction as being consistent with it. Under the category of ‘theory’, one of the specific concepts was labelled ‘person-centred counselling/therapy/theory’, but little material was coded there. In contrast, there was considerably more interview data categorised under the label ‘the psychologising of Intensive Interaction’. This category contained statements in which the participants used psychological language to talk about Intensive Interaction rather than making specific reference to a theory or therapy. 

To summarise: what the participants talked about when using Intensive Interaction and their comments about its benefits, can be best understood in Person-Centred Therapy terms; they described it as a means for establishing psychological contact. 



First impression taken from the interviews was that the participants seemed to be acting out of character for psychologists i.e. they were perhaps deliberately using prosaic or commonplace  language to describe complex psychological issues and perspectives. 

Upon reflection, the authors realised that they themselves were not fully confident about their own understanding of the psychological underpinnings of Intensive Interaction. Being limited by the dearth of psychologically based literature on the approach, they decided to re-visit Geraint Ephraim’s doctoral thesis and his subsequent publications on ‘augmented mothering’. In so doing, the authors anticipated that they would find a clear theoretical rationale for ‘augmented mothering’ against which they might compare the conceptualisations of Intensive Interaction by the clinical psychologist participants. This expectation, however, was not fulfilled. 



Finally, the authors stated that what is needed from clinical psychology is a more rigorously scientific approach involving theory development and testing via clinical case studies. Without a coherent process of theory development, and the systematic generation of an evidence base for a psychological model of Intensive Interaction, the approach is open to being dismissed as more commonplace than scientific. },

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@article{Harris2014b,

title = {Intensive Interaction: To build fulfilling relationships},

author = {Charly Harris and Emma Wolverson},

year  = {2014},

date = {2014-01-01},

journal = {The Journal of Dementia Care},

volume = {22},

number = {6},

pages = {27-30},

abstract = {In this paper the authors share their experiences of using Intensive Interaction (I.I.) to support people living in the later stages of dementia. 

Communication in dementia: The authors point out that dementia care experts have warned that people with dementia who no longer have speech are at risk of becoming socially isolated and disempowered. For families and staff, the breakdown in communication can be a significant source of stress in care giving. There is growing recognition of the importance of reciprocity in dementia care, and I.I. could potentially be a means to this end. 



The authors muted that some people may question I.I. for people with dementia given its origins in parent-child interactions. Also there are concerns that I.I. will not lead to cumulative improvements over time, due to the progressive nature of dementia. Despite such concerns, as I.I. focuses on social inclusion and emotional connectedness through meeting a person at their current level and allowing them to lead the interaction, this makes I.I. an approach that could offer structure and support to communication in advanced dementia.



The authors’ experience of using I.I.: For EW [a clinical psychologist] I.I. is especially useful when working with people who present with challenging behaviours – a sign that needs are unmet, often due to a communication breakdown. CH [a SLT] first used I.I. when working with adults with learning disabilities, but when she began working with people with dementia, she soon realised that their communication needs tended to be neglected, and so she continued to use I.I. whenever she thinks it appropriate.



CH researched the use I.I. with people with dementia: for the three participants in CH’s research, she found a sense of relationship development over the week of the study, and also in the following weeks. Two of the participants in particular also showed signs of engagement and social interaction, such as ‘looking at carer’, ‘vocalising’, ‘initiating’, ‘smiling / laughing’, which were more prominent in the I.I. session than in the standard interaction.



For one participant Mr D (who was bed-bound) I.I. gave him an opportunity to initiate interactions to control another person’s social behaviour e.g. moving his hand to his ear as CH sang. Mr D also started to change his vocalisations: outside of the I.I. sessions he vocalised loudly and constantly (it almost sounding painful), but shortly into the first I.I. session he began to adapt his vocalisations so that were gentler (mirroring CH’s sound): it felt like the give and take of a true conversation and led to a feeling of profound connection: basically, I.I. enabled Mr D to demonstrate areas of retained function which had been overlooked when relying on verbal interaction.



Mrs K flinched at touch and was isolated through her constant walking. She allowed the CH to join her on her stroll.  During sessions there were shared moments of laughter and game playing as Mrs K showed CH her favoured routes and routines. As the sessions progressed Mrs K allowed CH to gently touch her arm, and this eventually developed, much to the shock of observing staff, into twirling each other’s hair while she watched CH intently. Perhaps most important of all was Mrs K’s husband’s comment that for the first time in months she had made eye contact with him.



The study was small and exploratory, but the results suggest great potential for the use of I.I. with people with dementia and the impact it can have on their relationships and well-being.



Reflections on teaching I.I. to staff groups: In many ways I.I. training for staff has been about permission giving and encouragement and as such appears to have positive effects on self-esteem. Also as I.I. can be emotionally and physically demanding so ongoing supervision and support is also essential. Training and supervision take time and I.I. also requires time and patience, so ultimately a culture change in services is required where services can move away from models of reactive communication towards proactively seeking out ongoing dialogues and building trust.



Concerns and queries: Given the concerns of some staff, it is legitimate to consider the suitability of I.I. for people who once had full verbal communication. Staff do need to be careful when trying to access the changing levels of both receptive and expressive communication in people with dementia.  Therefore the author’s believe that personalisation is the key, and that means communicating in a way that has meaning for the person.

Concerns about the use of touch in healthcare settings have been common barriers to I.I. Also stereotypes about personal space and respect for older people have also been cited as a reason not to touch. Therefore for I.I. to be embraced, dementia care services need to develop person-specific touch guidelines. Given all these concerns, the authors observe that I.I. has demonstrated the potential to be renewing and transformative for staff.



Reflections on using I.I. with families: The authors note that family caregivers have been very interested in I.I. and also that when working with families the authors have found that many family caregivers automatically move into communicating in an I.I. manner having spent a lifetime already tuned into one another, recognising particularly the value of touch, delighting in all interactions.



Conclusion: The authors state that I.I. can be an approach to improving well-being in dementia, that respects personhood, adds quality to the working lives of staff, and reintroduces a bond based on fun and understanding.},

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@article{Firth2013,

title = {Training care staff in intensive interactions},

author = {Graham Firth and Charlotte Poyser and Nicola Guthrie },

url = {https://www.researchgate.net/publication/272698043_Training_care_staff_in_intensive_interactions},

doi = {DOI:10.7748/ldp2013.12.16.10.14.e1499},

issn = {7748-1499},

year  = {2013},

date = {2013-11-28},

journal = {Learning Disability Practice},

volume = {16},

number = {10},

pages = {14-19},

abstract = {Intensive interaction is a way of improving communication with children and adults who have severe or profound learning disabilities and/or autism. Research shows intensive interaction interventions often lead to more or new responses. This article discusses the Leeds NHS intensive interaction programme, which was developed to help staff implement the approach with individual service users. It also describes an evaluation of the programme during which feedback was generally positive and respondents said they would recommend the programme to other services.},

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tppubtype = {article}

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@article{Sharma2012,

title = {Effective Engagement through Intensive Interaction},

author = {Vishal Sharma and Graham Firth },

doi = {10.7748/ldp2012.11.15.9.20.c9380},

year  = {2012},

date = {2012-10-31},

journal = {Learning Disability Practice},

volume = {15},

number = {9},

pages = {20-23},

abstract = {This paper reviews research on the effects of Intensive Interaction on the conduct, health and wellbeing of people with learning disabilities who exhibit severe challenging behaviour, and on the wellbeing of their carers.  The authors conclude that Intensive Interaction can benefit clients, carers and staff, but that research is required to encourage developments in policy and practice, and that additional staff training is needed to ensure that Intensive Interaction strategies can succeed.



The authors describe how individuals with severe and/or profound and multiple learning disabilities (S/PMLD) and/or autism may present with severe challenging behaviour, this is ‘behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy’ (Emerson et al, 1988).  Such behaviours can include, but are not limited to, head banging, punching and biting (Oliver, et al., 2003).

The authors also point to a contrasting perspective by Ephraim (1998) that there is no such thing as severe challenging behaviours, and that these are socially aberrant forms of communication i.e. ‘A punch in the face’ is an act of communication, although the message behind the punch may not be understood.



The paper goes on to review existing research with differing results as to the effectiveness of Intensive Interaction in reducing the severity and/or frequency of severe challenging behaviours in individuals with S/PMLD and/or autism (Caldwell, 2010; Nind and Hewett, 2005).

However, the authors mention that previous research suffers from a number of methodological limitations, such as small sample sizes (Elgie and Maguire, 2001), varying practitioner ability/experience (Zeedyk, et al., 2009), varying definitions of “challenging behaviour” and a lack of objective assessment of behaviour pre- and post-Intensive Interaction interventions (Irvine, 2001). These limitations hinder the ability to generalise findings across user groups, and may also explain the lack of adoption of Intensive Interaction by learning disability services.  As such, further methodologically robust research is requested by the authors.



In conclusion the authors suggest that the current body of research indicates that Intensive Interaction techniques can reduce the severity and frequency of severe challenging behaviours, and improve the health and wellbeing of individuals with S/PMLD.  Moreover, viewing the behaviours as a form of communication (Ephraim, 1998) suggests that carers need to ‘learn the language’ of their clients or service users.  Thus, Intensive Interaction encourages carers to listen to and understand what individuals are saying with their body language and facial expressions.  



It is also the author’s view that by adopting Intensive Interaction techniques, staff can communicate more effectively with people with S/PMLD, and introduce them to new worlds of social interaction.  



Finally the authors propose that further evidence of the benefits may encourage policy makers and practitioners to adopt Intensive Interaction practices, thereby enabling individuals with S/PMLD and their families to achieve a better quality of life.},

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@article{Argyropoulou2012,

title = {The training of a child with autism in a Greek preschool inclusive class through intensive interaction: a case study},

author = {Zoe Argyropoulou and Despina Papoudi},

doi = {https://doi.org/10.1080/08856257.2011.640489},

issn = {0885-6257},

year  = {2012},

date = {2012-01-11},

journal = { European Journal of Special Needs Education},

volume = {27},

number = {1},

pages = {99-114},

abstract = {This study examined social interactions during play between a young boy with autism and a typically developing girl, before and after the boy was trained by his teacher through intensive interaction. 



Method: This study, conducted in a preschool inclusive class in a school in Athens, concerned a 6-year old boy (Philippe) who presented several key features of autism including social isolation, echolalic speech, and ritualistic behaviours. A girl, Anna with a highly developed sense of empathy, was selected as the boy’s play partner. A range of materials and toys were made available during the sessions to facilitate verbal and non-verbal communication. 



The two month study used an ABA single case design, with the data recorded in three different phases, baseline (A1), post-training (B) and follow-up (A2).  Each phase included five sessions of 10-15 minutes over two weeks, session being videotaped and the first author keeping field notes. The children were told that the purpose was ‘playing to have fun’.



Baseline Phase A1: to observe the children’s behaviour to provide a baseline.

Training phase: in this phase the researcher used the same play materials used during Phase A1 and ‘Intensive Interaction’ techniques were used. Each session was followed by a play session between the two children. 

Phase B – post training: to assess the effectiveness of the training of Philippe. The play materials remained the same. It was hoped that the ‘training’ would increase Philippe’s desire to interact with Anna. 

Phase A2: in this phase the training was withdrawn and the conditions of Phase A1 re-established.   



Measurement: The success of the training was judged by coding the children’s social behaviours which were categorised as initiations and responses. For each initiation, the other child’s response, positive or negative, was recorded. All the data was videoed, social interactions coded, and categorised. Initiations included (a) waiving to or holding the other child’s hand; (b) drawing attention to an object or activity; (c) verbal communication, i.e. making a verbal initiation or asking something of the other child; (d) body contact, i.e. kissing or cuddling the other child: and (e) giving a toy or initiating a game.  

A ‘response’ was defined as a behaviour which followed a social behaviour by the other child. These were coded as ‘positive’ if a child answered a question, obeyed an order, responded positively or imitated the actions of the other child. ‘Negative’ responses included: (a) avoidance, when the child looked/moved away, pushed him/her, closed his eyes and did not respond when called; (b) aggressiveness when the child pushed, pulled, or scared the other child. 



Results 

Philippe’s initiations and Anna’s responses: From Phase A1 to B, the number of Philippe’s initiations increased from 16 to 28. From Phase B to A2 the number of Philippe’s initiations returned to the level of Phase A1. From Phase A1 to A2 there was an increase in the percentage of positive responses of Anna of 33%.

Anna’s initiations and Philippe’s responses: From Phase A1 to B there was an increase of positive responses by Philippe of 460%. From Phase B to A2, the number of Anna’s initiations decreased from 39 to 28 (28%). From Phase A1 to A2 the number of Anna’s initiations increased from 11 to 28 (155%). In Phase A2 71% of Philippe’s responses were positive and 29% negative, with an increase in Philippe’s positive responses of 300%. Philippe’s social behaviour changed after training, during Phase B - Philippe’s initiations increased by 75%, with a 144% increase in his positive responses. During Phase A2 Philippe’s positive responses remained higher, reaching 72% of his total responses and decreasing only to 71% in Phase A2. This suggests that the withdrawal of training influenced the initiation level but not the level of the child’s positive responses, a fact that might be explained by emotional intimacy that was created between the two children. 

Before the research Philippe and Anna were acquainted but were not playing together. After the study, Anna and other peers were initiating contact with Philippe and tried to include him in their games.  Philippe responded positively when with the children and seemed happy. Sometimes Philippe also made initiations to Anna. During Philippe’s training a detailed sessional diary evidenced improvements in his social and emotional engagement, eye contact, verbalisations, body orientation and contact, and smile from the first session onwards. 



Conclusion: This study showed that ‘Intensive Interaction’ helped a child with autism to increase his social engagement. His initiations increased in the post training phase but returned to the initial level in the follow up phase.  However, his increased levels of positive responses to the peer’s initiations remained at a high level post training. 



Overall, the results of this study accord with the findings of previous research.  Firstly, children with autism are more likely to engage with someone if that person provides active input.  Secondly, such input is more effective when it ‘scaffolds’ the child with a disability through Intensive Interaction and interactive play. Lastly, 1-to-1 peer to target child ratio increases the likelihood of social initiations and interactions between a child with autism and his peer. 

Naturally, a single case study during a short time period is limited, with inherent problems of generalizability.  Further research is needed to determine how such ‘Intensive Interaction’ training can be applied in order to help the social interaction between children with communication difficulties and their peers in mainstream settings.    },

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tppubtype = {article}

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@article{Fraser2011,

title = {Can adults on the autism spectrum be affected positively by the use of intensive interaction in supported living services?},

author = {Catherine Fraser},

issn = {1466-2973},

year  = {2011},

date = {2011-10-31},

journal = {Good Autism Practice},

volume = {12},

number = {2},

pages = {37-42},

abstract = {In this paper the author CF (a residential  service manager) stated that people who cannot communicate verbally are often not communicated with effectively, and this was why she was interested in Intensive Interaction (I.I.).



The case study: Derek was a man of 67 years with a diagnosis of autism and epilepsy. He had lived in the same supported living setting for 9 years. Derek sometimes displayed behaviours that were challenging e.g. incontinence; screaming and shouting at others; repetitiveness; withdrawing to his room for long periods; switching lights on and off; pulling his finger nails off. These behaviours were described as ‘agitated behaviour’. In order to judge the effectiveness of I.I., CF decided to record the frequency of these behaviours during and after the intervention.



When at home Derek had 1-to-1 support, and also attended a day centre five days a week. He communicated using words (singly or as a short ‘string’), gestures, and by pointing. When using I.I. with Derek, CF decided to work ‘instinctively’, only using speech when she deemed it to ‘fit’. One of the common interactions initiated by Derek was to talk about colours: Derek: “Colour” (pointing to a gold button) … CF: “Gold” … Derek: “Gold colour” … CF: ”Gold colour” … Derek: “Nice colour Ha Ha” (laughing) …  CF: “Nice gold colour”



Derek appeared to respond positively to this interaction (he laughed, smiled and used eye contact), but this would not have happened prior to the introduction of I.I.. His support team tended to talk to him using full sentences as illustrated here: Derek: “Colour?” (pointing to some flowers) … Support Worker: “The flowers are yellow, where did you get them from?” … Derek: “Yellow” … Support Worker: “I asked you where you got them from Derek” … Derek did not respond and sat quietly.



Aims: CF’s stated aim of the I.I. was to develop more individual conversations rather than a prescriptive list of how to react. From observation Derek’s common movements and sounds were identified, giving an indication of what he might recognise.



Results and evaluation: When first using I.I. CF felt that Derek wasn’t showing any interest in her, preferring to seek out his support worker. After a few sessions the first shared interaction was a sigh, with a loud ‘blowing out’ sound. Derek did this and CF echoed it, and then Derek gave a very brief sideways glance towards CF. As the sessions went on, this interaction built up until one day as CF arrived Derek immediately sighed: it felt like they now had a meaningful way to say “Hello”. 



During session 3 Derek used CF’s name. When CF arrived for session 5, Derek’s support worker took her to his room (where he was watching TV) and said: “Derek, Catherine is here”, at which point Derek said “Catherine” and smiled and jumped up from his bed. During session 8 Derek used sustained eye contact for the first time. CF found these signs of progression exhilarating and encouraging, to her it was a sign that the I.I. sessions were having a positive effect on Derek.



To increase the reliability of the findings CF met with Derek’s support team and asked them for their observations. One comment was that Derek had started asking when CF would next come. Other changes agreed by the team members were:

Derek had started spending more time in the lounge than his bedroom.

Derek had started interacting more with his fellow service-users.

Derek was more likely to complete activities with his support worker, and had stopped flicking lights on and off.

The amount of time Derek spent listening to music through headphones had reduced.

Derek appeared more patient, and did not invade other people’s personal space as much as he did before.

Generally the observations from the staff team showed an increase in sociability and a decrease in behaviours that challenged



Concluding comments: When evaluating this study CF stated that a research should consider any other factors which may have affected Derek’s behaviour, but then noted that there were no changes in the level of Derek’s support, or in the number of family visits and no significant changes to his health. CF also noted that there was no control or comparison data, making it impossible to conclude that the changes were directly due to the I.I., but CF states that this might well have been the case, and that there was no evidence to suggest that the I.I. caused any regression in his emotional state or behaviour.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Nind2011,

title = {Enhancing the communication learning environment of an early years unit through action research},

author = {Melanie Nind},

url = {https://www.tandfonline.com/doi/pdf/10.1080/09650790300200226?needAccess=true},

doi = {https://doi.org/10.1080/09650790300200226},

issn = {0965-0790},

year  = {2011},

date = {2011-02-08},

journal = {Educational Action Research},

volume = {11},

number = {3},

pages = {347-63},

abstract = {This article reports on an action research project in which an external consultant, special educational needs coordinator and staff of the early years unit of a mainstream school worked together to understand and enhance the communication learning environment provided for 3-5 year-old pupils. A transactional rather than deficit model was adopted, such that bi-directional influences in communication difficulties and communication learning were fully recognised. The focus for deliberation and action was the role, style, talk and interaction behaviour of the adults. Concepts of optimal interactive styles from studies of caregiver–infant interaction were applied. Activity included a mixture of observation, discussion and reflection on current and changing practice and related research. Developments evolved that were judged to have enhanced the communication learning environment, including increased use of small group time and greater use of child-led ‘show and tell’ and sharing time. The article is written from the perspective of the external consultant and includes discussion of the action research process.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}