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The Effectiveness of Intensive Interaction,
A Systematic Literature Review
Nick Hutchinson*and Anna Bodicoat
†
*Department of Clinical Psychology, Hull York Medical School, University of Hull, Hull, UK;
†
Department of Psychological Health and
Wellbeing, University of Hull, Hull, UK
Accepted for publication 22nd October 2014
Background Intensive Interaction is an approach used for
communicating with people with profound and
multiple intellectual disabilities or autism. It has gained
increased recognition as a helpful technique, but the
evidence has not been systematically reviewed.
Method Computerized and hand searches of the
literature were conducted using synonyms for
‘intellectual disabilities’, ‘autism’ and ‘intensive
interaction’.
Results Fifteen quantitative and three qualitative papers
were identified examining the efficacy of the approach
with participants across the age range in both
educational and residential settings.
Conclusions Studies were limited by the quality of
reporting and difficulties conducting good quality,
ethically sound research with participants with PMID.
Staff support should be considered in training to aid
implementation of interventions. Studies attempted to
investigate whether Intensive Interaction builds social
interactions or reduces repetitive or self-injurious
behaviour. More research needs to be conducted before
conclusions can be drawn regarding the efficacy of this
approach.
Keywords: autism, intellectual disabilities, intensive
interaction, profound and multiple intellectual dis-
abilities
Introduction
Intensive Interaction is a technique of communication
with people who do not use words, for example those
with profound and multiple intellectual disabilities
(PMID) or autism. The approach uses pre-verbal
communication techniques for instance responsive eye
contact, facial expressions, vocal mirroring and joint
focus activities (Nind & Hewett 2001). Just as a mother
would imitate and turn-take with an infant, a
practitioner using Intensive Interaction would develop
imitations into mutually enjoyable games and build a
relationship with a person with an intellectual disability
(Nind & Hewett 2001).
This approach has increasing recognition among
healthcare practitioners, teachers and carers. There are
several books (Nind & Hewett 2001; Caldwell 2007;
Zeedyk 2008; Firth et al. 2010), an ‘Intensive Interaction
Institute’, and conferences in both the United Kingdom
and Australia. It is recommended in ‘Valuing people
now’ (Department of Health 2009), as beneficial for
people with PMID, and suggested for a therapeutic
approach with behaviours seen as challenging (Sharma
& Firth 2012). It has begun to be investigated as an
approach to be used with people with end-stage
dementia (Ellis et al. 2008).
In some literature, there is a distinction between social
and educational aims of Intensive Interaction. Some
practitioners see Intensive Interaction as a tool to develop
communication skills (Nind & Hewett 1994; Kellett 2000,
2003, 2004, 2005; Nind & Kellett 2002), whilst others see
its potential as a route to social engagement and inclusion
(Leaning & Watson 2006; Caldwell 2007). Firth (2009) has
developed a model combining these perspectives. In the
‘Dual Aspect Process Model’, Firth states that processes
seen are evident at two different time points of using the
approach. After the initial adoption of Intensive
Interaction, there is an increase in social inclusion and
communication resulting from the inclusive responses
to the person’s communicative behaviour. Firth (2009)
states that after a time the client’s communication
plateaus at a ‘transition phase’. Communication abilities
©2015 John Wiley & Sons Ltd 10.1111/jar.12138
Journal of Applied Research in Intellectual Disabilities 2015
Published for the British Institute of Learning Disabilities
subsequently develop long term. Evidence cited for the
Dual Aspect Process Model is the variable time period of
research, with shorter studies (from 3 days to 16 weeks)
focusing on developing social inclusion (Lovell et al.
1998; Elgie & Maguire 2001) and longer studies
examining the new abilities (Nind 1996; Kellett 2000,
2003, 2004, 2005). This has important implications
for teaching, training and staff support, such as how
long training should last to be effective, how soon
practitioners may see changes, and how much staff
support there should be.
It has been suggested that difficulties in comm-
unication skills are linked to self-injurious behaviour
(Duncan et al. 1999). Repetitive behaviour could be as a
consequence of lack of social inclusion and social
engagement (SoHyun et al. 2007). Therefore, an
intervention which targets social inclusion may reduce
self-injurious behaviour and repetitive behaviour.
In reviews of the literature (Firth, 2006; Sharma &
Firth 2012), research on Intensive Interaction has been
identified to be limited in scope and scale, with the
studies often being case studies because empirical
investigation of Intensive Interaction is challenging to
conduct. The published research has not been
systematically reviewed nor assessed for quality. This
will be addressed in the following review and
recommendations will be given regarding the scope and
methodology of future studies.
Research question
What are the effects of using Intensive Interaction with
a person with an intellectual disability or autism on
social communication, self-injurious behaviour and
repetitive behaviour? Are these effects influenced by the
training of practitioners or staff experience?
Materials and Methods
Search strategy
A computerized search on Intensive Interaction and
people with intellectual disabilities or autism was
conducted in August 2013 on databases up to and
including this date. Databases included were CINAHL,
PsychInfo, Medline, ERIC and Web of Science. The
search terms used were synonyms for ‘intellectual
disabilities’ or ‘autism’ combined with synonyms for
‘Intensive Interaction’, as below:
‘menta*deficien*’ OR ‘mental*handicap*’OR
‘mental*retard*’ OR ‘mental*impair*’ OR ‘mental*
disab*’ OR ‘mental*subnormal*’ OR ‘learning disab*’
OR ‘learning difficult*’ OR ‘intellectual difficult*’OR
‘intellectual*disab*’ OR ‘intellectual*impairm*’OR
‘developmental disabilit’ OR autis*OR ASD OR
‘Preverbal’OR‘Prelingual’ OR ‘develop*dela*’ AND
‘Intensive Interaction’ OR ‘augmented mothering’ OR
‘Hanging out program’ OR ‘From Inside Looking Out’
OR FILO OR ‘imitative interaction’.
Articles which had the terms in their abstract or title
were included. The inclusion and exclusion criteria were
applied to the abstract or the full article if this was still
ambiguous.
No systematic review had been conducted in this area
before, and the literature base is known to be small, so
no cut-off date was employed. A research review on the
Intensive Interaction Institute website was also
consulted, which highlighted five further articles
published in peer-reviewed journals, and key authors
were contacted to ascertain if there were any further
studies which had not been found in the databases.
Inclusion and exclusion criteria
Studies involving both people with intellectual
disabilities and people with autism were included, as
there is comorbidity between the two conditions. No
age restrictions were applied as both intellectual
disabilities and autism are lifelong conditions.
Due to Firth’s (2009) Dual Process Model, studies
from both social and educative backgrounds were
included. It is likely that many studies contain both
elements from the Dual Process Model, and dividing
such a small literature base would be unwise.
No restrictions were placed on the form or amount of
practitioner training in Intensive Interaction, as there is
no standardization of training.
All studies which focused on the outcome of an
Intensive Interaction intervention were included. Studies
could use a quantitative or qualitative methodology;
however, purely narrative descriptions of case studies
were excluded, due to the difficulty in assessing
methodological quality, in particular, with regard to
controlling for extraneous variables or the author’s
acknowledgement of bias.
Study screening
Inclusion criteria
Studies including: (i) participants of any age with an
intellectual disability or autism, (ii) using intensive
©2015 John Wiley & Sons Ltd
2Journal of Applied Research in Intellectual Disabilities
interaction as an intervention, (iii) examining the effect
(s) or outcome (s) of using Intensive Interaction and (iv)
in a peer-reviewed journal, or be in the process of
submitting to a peer-review journal for publication.
Exclusion criteria
Studies excluding: (i) literature reviews or non-empirical
papers and (ii) studies which are not written in English.
Quality assessment
Studies were not excluded based on quality. With such
a small literature base, it was more helpful to critique
all papers found and use the deficits in quality to
inform future research.
Many studies in this review adopted single case
experimental designs; quality assessment has been
comprehensively discussed by Smith (2012). The single
case experimental design (SCED) checklist (Tate et al.
2008) was utilized. No adaptations were made, as it was
comprehensive enough to distinguish between papers.
This is the only scale assessing single case designs
which has been assessed for its psychometric properties.
The checklist comprises 11 questions regarding different
aspects that add to the quality of single case
experimental design.
Some studies utilized a qualitative methodology, and
these were assessed using a quality framework from the
National Institute for Health and Care Excellence
(National Institute for Health & Care Excellence 2012).
This was developed by reviewing a variety of
frameworks for qualitative research and consists of 13
questions. It does not have scores associated with it, so
to enable comparison, each point was assigned ratings
of either 0 (omitted or inadequate), 1 (poor), or 2 (good)
and these were used to compare studies.
To reduce the potential for bias in the reporting, 20%
of the SCED papers and all qualitative papers were
rated by a second marker.
Results
The results of the search strategy can be seen in
Figure 1.
Characteristics of papers
Fifteen of the papers were found to be single case or
small ‘n’ designs, three of the papers used a qualitative
methodology. The papers are presented in Table 1.
The 53 different participants across the studies ranged
in age from 5 years old to early 60s, there were 22
female participants and 23 male, with the remainder not
stating the gender. Twelve of the studies were from the
United Kingdom, two were from Australia, one was
from Greece, and one was from Romania. One of the
papers included (Nind & Kellett 2002) used data which
had been presented elsewhere (Nind 1996; Kellett
2000).These studies were included, despite the
duplication of participants, as each paper had a
different focus and reported different results from the
evidently large amount of data that the researchers
collected.
Quality assessment
Quantitative studies (N =15)
The studies included were all single case or small n
designs. When the studies were scored using the SCED
(Tate et al. 2008), there was a range of 3–9 of 11. The
sum of scores can be seen in Table 1. Twenty percent of
the studies were rated by a second marker and the
ratings received a Cohen’s Kappa score of 0.817 which
is classed as ‘very good’ (Fleiss 1973).
In general, the studies reviewed suffered from failing
to control potential sources of bias, or, at least, failing to
report how they controlled for bias as this was the
second lowest scored category of all the checklists. The
lowest scored category was statistical calculation, which
all but one of the papers (Samuel et al. 2008) failed to
do. Statistical calculation in single case designs is
notoriously under-utilized (Smith 2012), so this finding
is unsurprising. In addition, sometimes the way results
were reported made it difficult for the author’s
conclusions to be fully supported.
Qualitative studies (N =3)
The qualitative studies were reviewed using the NIHCE
scale (National Institute for Health & Care Excellence
2012). There was a range of 10–21 of 26. The studies
suffered from a lack of clear reporting and reflexivity
with regard to the choice of methodology and the
researcher’s position. The sum of scores can be seen in
Table 1. All three papers were second marked and
received a Cohen’s Kappa of 0.643, classed as ‘good’
(Fleiss 1973). Of particular quality was the study
conducted by Zeedyk et al. (2009a,b), as this study
clearly stated methodology and process and extensively
linked the findings back to previous literature.
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 3
Synthesis of findings
The results will be presented as a narrative synthesis,
with themes of: training of practitioners, effectiveness of
intensive interaction, staff experience, anecdotal
evidence and sustainability of interventions.
Training of practitioners
The training of Intensive Interaction practitioners and
the subsequent length of time for the intervention
varied considerably. Ten studies (Nind 1996, 1999;
Jones & Williams 1998; Lovell et al. 1998; Elgie &
Maguire 2001; Nind & Kellett 2002; Kellett 2003;
Leaning & Watson 2006; Zeedyk et al. 2009a,b;
Argyropoulou & Papoudi 2012) did not state the
training given to the practitioners; for six studies, it
was a day or less (Kellett 2000, 2004, 2005; Forster &
Taylor 2006; Samuel et al. 2008; Zeedyk et al. 2009a,b);
for two studies (Barber 2008; Jones & Howley 2010), it
was longer (10 sessions and six sessions respectively).
Four studies (Forster & Taylor 2006; Barber 2008;
Samuel et al. 2008; Jones & Howley 2010) stated that
there was follow-up support afterwards, such as
reflective groups for the staff.
As far as can be ascertained in the studies reviewed,
the outcomes did not vary according to the length of
training given. Several authors did discuss limitations in
the training or subsequent support for practitioners and
concluded that lack of support from management
negatively affected the efficacy of the approach (Kellett
2003; Samuel et al. 2008).
Effectiveness of intensive interaction
Studies reviewed and examined aspects of participants’
behaviour to ascertain what effect Intensive Interaction
had, and these were social interaction and interactions
with peers, self-injurious behaviour and stereotyped
behaviour.
Social interaction
Social interaction or engagement has been measured
differently across the studies, usually by coding videos
for behaviours indicating social engagement. Many
Figure 1 Results of search strategy.
©2015 John Wiley & Sons Ltd
4Journal of Applied Research in Intellectual Disabilities
Table 1 Details of studies included in the review
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
Quantitative studies
Argyropoulou
& Papoudi
2012
N=1
Age =6
Gender =M
Country =Greece
Context =autism
diagnosis, worked
with a peer, ‘Anna’
in an inclusive class
at a mainstream
school
To examine the
effect of Intensive
Interaction (II)
intervention on
social interaction
peers
Used by: teacher
(the researcher).
Training and
support: Not
stated
Intervention: II
‘training’ sessions
occurred 3 times
per week for
2 weeks, lasting
approximately
12 min.
Play sessions with a
peer occurred
directly after the
training sessions
ABA design,
video recording
of the children’s
play sessions.
Phase
A1 =before the
training started,
Phase
B=directly
after training
sessions,
Phase
A2 =training
sessions
discontinued
Videos were coded for
acts from each child
that were attempts to
initiate social
interactions
(‘initiations’) and the
children’s positive and
negative responses to
such initiations
Increase in initiations
Increase in positive
responses from both
children from phase
A1 to B but no change
in phase B to A2.
Increase in positive
responses from play
partner
8/11
Barber 2008 N=3
Gender =does not
state
Country =Australia
Context: pupils with
autism diagnoses
who attend a
special school
To examine
whether an II
intervention
changes
communicative
behaviour of
pupils and staff
Used by: classroom
staff.
Training and
support: 10 after-
school seminars.
Staff reflection
groups. Videos to
aid reflection.
Intervention:
30 weeks of II
used during
‘downtime’
AB design.
Videos recorded
before and after
intervention
Videos coded for
‘Indicators of
involvement’:
No interactive
behaviours,
look at face, smile,
socially directed
physical contact
(SDPC), engagement
Decrease in ‘no
interactive behaviours’
for all participants.
Increase in ‘look at face’
for 2 participants.
Increase in ‘smile’ for
one participant.
Increase in SDPC for
all participants.
Increase in engagement
for all participants
6/11
Elgie &
Maguire 2001
N=1
Age =39
Gender =F
Country =UK
Context: person with
a profound
intellectual
disability who was
blind
To assess the
effectiveness of II
with someone
who was blind
and had a
profound LD
Used by: Clinical
Psychologist and
Trainee
Psychologist
Training and
support: not
stated.
Intervention: 3
times per week for
16 weeks
Hand contact
and Self-
Injurious
Behaviour (SIB):
AB design,
6 month
baseline.
Vocalizations: BA
design
Frequency of hand
contact.
Frequency of SIB in a
25 min period every 3
or 4 weeks for
16 weeks.
Frequency of
vocalizations during
and after one session
No change in SIB.
Increase in hand
contact.
Decrease in
vocalizations after
session
3/11
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 5
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
Jones &
Williams
1998
N=1
Age =35
Gender =M
Context =person
with intellectual
disability and
limited eyesight
To find out
whether
stereotyped
behaviour was
influenced by II
or a proximity
intervention
Used by: care staff
member.
Training and
support: not
stated.
Intervention: 1
session, half
imitation and half
proximity
Alternating
treatments of
100-second
intervals
Frequency of stereotypy
during intervals
Neither condition
influenced the
stereotypy
7/11
Kellett 2000 N=1
Age =5
Gender =M
Country =UK
Context: child with
autism and severe
developmental
delay, ‘Sam’
To evaluate the
efficacy of II
Used by: staff
member at school.
Training and
support: 1-day
workshop.
Intervention: 15–
20 min per day for
3 months
AB design of one
participant (Part
of a larger,
multiple-
baseline study)
12-week
baseline
Videos coded for 8
indicators of social
behaviour:
no interactive
behaviours,
looking at face, happy/
smiling face, reciprocal
social physical contact,
eye contact,
joint focus/activity,
contingent
vocalization,
engaged. Pre-Verbal
Communication
Schedule (PVCS)
(Kiernan and Ried,
1987) and Physical
Sociability Assessment
Scale (Nind, 1993)
Decrease in ‘No
interactive behaviours’
(following unstable
baseline).
Increase in
‘engagement’.
Looking at or towards
face: increase from
near zero to 52%
Social physical contact,
contingent vocalization
and eye contact: all
modest increase from
very low baseline
scores.
Joint focus: following
unstable baseline, post-
intervention scores
increased but variable:
attributed to
interruptions from
holiday periods.
PVCS increases from 0%
to near 90%.
Physical sociability
assessment scale:
Increase from 1 to 4 of
8
7/11
©2015 John Wiley & Sons Ltd
6Journal of Applied Research in Intellectual Disabilities
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
Kellett 2003 N=1
Age =8
Gender =M
Country =UK
Context: child with
severe generalized
developmental
delay with physical
impairments and
epilepsy, ‘Jacob’
To evaluate the
efficacy of II
Used by: teaching
assistant.
Training and
support: not
stated.
Intervention: daily
time, scheduled
for 42 weeks –but
week 13 to week
24 missed due to
staff injury
AB design of one
participant (Part
of a larger,
multiple-
baseline study)
5-week baseline
As in Kellett’s 2000
study, above.
Percentage incidence of
stereotypical
behaviours during
intervention and in
class
Decrease in ‘No
interactive behaviours’.
Increase in
‘engagement’, some
variability which was
attributed to teaching
assistant being off
work for/the prior
weeks.
Looking at or towards
face and joint focus:
increased (from
average of 8.4% to 48%
and 3.7% to 65%
respectively).
Variability attributed
to teaching assistant’s
absence.
Social physical contact,
contingent
vocalization, and eye
contact: increased.
PCVS increase from
14.3% at baseline
stages, to 56.6% at end
of study.
Physical sociability
assessment scale:
increase from 3 to 8 of
8.
Drop in incidence of
stereotypy in sessions
and class
8/11
Kellett 2004 N=1
Age =6
Gender =M
Country =UK
To evaluate the
efficacy of II
Used by: teacher
and two assistants.
Training and
support: 1-day
AB design of one
participant (Part
of a larger,
multiple-
As in Kellett’s 2000
study above, but
PCVS and Physical
‘Engagement’, looking
at face, social physical
contact, eye contact,
and ability to attend to
6/11
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Journal of Applied Research in Intellectual Disabilities 7
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
Context: child with
severe autism ‘Finn’
workshop.
Intervention: 15–
20 min per day for
3 months
baseline study).
6-week baseline
Sociability Scale not
reported
a joint focus all
increased, with
variability attributed to
holidays and illness.
Gains were not evident
in classroom setting,
attributed to a lack of
support for the
approach
Kellett 2005 N=1
Age =11
Gender =F
Country =UK
Context: child with.
profound
intellectual
disabilities and a
fragile life
expectancy,
‘Catherine’
To evaluate the
efficacy of II
Used by: teacher.
Training and
support: 1-day
workshop.
Intervention: 4
Sessions,
intervention
interrupted due to
death of
participant
AB design of one
participant (Part
of a larger,
multiple-
baseline study)
7-week baseline
As in Kellett’s 2000
study above but social
physical contact and
engagement less
relevant due to
movement difficulties
There was an increase
in eye contact and joint
focus
7/11
Leaning &
Watson 2006
N=3
Gender =2xF, 1xM3
Age =28–38
Country =UK
Context: people with
PMID in a group
setting
Evaluate the
effectiveness of an
II group
Used by: music
therapist and
trainee
psychologist.
Training and
support: not
stated.
Intervention: 8-
week group for
50 min per week
Multiple
participants
ABA design.
1 baseline session
Video recording and
coding for:
Eye contact (other), eye
contact (object),
smiling, active
avoidance and self-
stimulation
Increase in all social
behaviours for 3
participants. Decrease
in active avoidance
and self-stimulation,
variable results
attributed to session
cancellation
6/11
Lovell et al.
1998
N=1
Gender =M
Age =53
Country =UK
Context =person
with PMID at a
long-stay hospital
Evaluate the
effectiveness of II
to increase social
behaviour with a
man with PMID
Used by: Clinical
Psychologist.
Training and
support: not
stated.
Intervention: 3 days
of alternating
5 min interaction
Alternating
treatments
Video coding: physical
contact,
client looking at any
other person,
joint awareness,
smiling/laughing,
looking at toy,
covering at least half
Increase in physical
contact, looking at
people and joint
attention in the II
sessions.
No consistent changes
in vocalizations, smile/
laughing, and looking
6/11
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8Journal of Applied Research in Intellectual Disabilities
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
and proximity
sessions (17
sessions (total)
of his face with his
clothes
at toy.
Reduction in covering
face with clothes in II
sessions, following an
unstable baseline
Nind 1996 N=6
Gender =does not
specify
Age =27–36
Country =UK
Context =people
living in a long-stay
hospital
Evaluate the
effectiveness of II
in developing the
social and
communicative
abilities of people
with PMID
Used by: teacher.
Training and
support: not
stated.
Intervention: 12–
18 months of daily
sessions
Multiple baseline Video coding: initiation
of social contact,
response to physical
contact & proximity
interactive behaviours.
PVCS and cuddliness
scale
Increases in initiation of
social contact and
increases in time spent
in interactive
behaviour in 5
participants. New
interactive behaviour
in some participants.
Advances in PVCS and
cuddliness scale for all
participants
7/11
Nind 1999 N=1
Age =28
Gender =M
Country =UK
Context: person with
autism, living at a
long-stay hospital
‘Kris’.
Questionnaires
regarding
‘Interactive
Approaches’ filled
out by 58 teachers
in a variety of
schools, 11 of
whom described
using II
Is II useful with
people with
autism?
Used by: teacher
Training and
support: not
stated.
Intervention:
57 weeks
AB design of one
participant (Part
of a larger,
multiple-
baseline study).
Questionnaire
Video ratings:
organized self-
involvement, overall
time in interactive
behaviours, initiation
of social contact,
responses to proximity
and physical contact.
No particular analysis
of the questionnaires
stated
Unstable baseline
prevents full analysis,
but there is a drop in
self-involvement.
Increase in sociability.
No respondents
highlighted difficulties
in using II with
students with autism.
Benefits for learners:
increased self-
motivation, and
sociability, increased
calm.
Benefits for staff:
improved motivation,
feeling positive about
the children and work,
being receptive to
pupil’s signals
6/11
6/11
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 9
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
Nind &
Kellett 2002
N=6 Adults in
long-stay hospital
(As in Nind 1996)
4 Children at
community special
school (As in Kellett
2001;
2
)
Explore thinking
around
stereotyped
behaviour
Used by: teachers.
Training and
support: not
stated.
Intervention: 12–
18 months of daily
sessions
Original designs:
multiple
baselines. Data
presented: mix
of multiple
baseline and AB
design
Video coding of
individual stereotyped
behaviours –both in
and out of
intervention sessions
Reductions in
stereotyped behaviour
for some participants.
Lack of change in
behaviour ratings for
others attributed to
change in quality
rather than quantity of
behaviour, or lack of
support from wider
system
Samuel
et al. 2008
N=4 adult
Gender =F
Age =23–56
Country =UK
To investigate
whether novice
practitioners can
learn to use the II
approach.
To investigate
whether II has a
positive effect on
people with PMID
and the
relationship
between person
and
communication
partner
Used by: residential
care staff.
Training and
support: half day
with II
practitioner.
Intervention: 5
sessions per week
for 12 weeks
Staggered
multiple
baselines.
Questionnaire
administered,
content analysis
used
Coding of participants
on visual scanning,
looking at face,
engagements, joint
focus, initiating social/
physical contact.
Coding of staff on
mirroring vocalization
and movement,
contingent responding,
forcing/overriding
Questionnaire
Participants –increase
in visual scanning,
looking at face,
engagement, joint
focus, initiating social
contact.
Staff –increase in use of
mirroring vocalization
and movement and
contingent responding.
Completion of reflective
logs declined over
time.
Data from the
questionnaire were
most often coded as:
Team cohesion
Benefits for staff:
Only 3 of 58 observer
and practitioner
comments included
‘reciprocal relationship
building’
9/11
Zeedyk et al.
2009a,b
N=10
Gender =6xM, 4xF
Age =‘late teens to
To investigate how
quickly an
increase in
Used by:
experienced
practitioner.
Observational,
multiple cases
Section of video of the
first II session. Videos
coded: eye gaze to
Of 37 measures of
engagement, 5 did not
show an increase. At
6/11
©2015 John Wiley & Sons Ltd
10 Journal of Applied Research in Intellectual Disabilities
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
early 60s’
Country =UK
Context =in
residential centre,
day centre or at
home
engagement
occurs during II
Training and
support: not
stated.
Intervention: 1st
session of II
partner, bodily
orientation &
proximity to partner,
emotional valence.
Scores summarized as
‘engagement score’
least some variables
increased for all
individuals, 70%
increased on all
variables. Some
increases in
engagement
occurred within 3 min
Qualitative studies
Forster &
Taylor 2006
N=1
Gender =M
Age =‘young adult’
Country =Australia
Context =‘Cameron’
has PMID, severe
vision impairment
and physical
disability.
Two disability
support workers
(DSWs) interviewed
To document
communication
skills and staff
perceptions of
interactions
Used by: 9 DSWs.
Training and
support: 2 h trial
of II, consultation
report detailing II
recommendations,
reflective logs.
Intervention: daily
interaction
sessions with
Cameron, from
15 min to 2 h in
duration
Videoed
observations of
2 DSW with
Cameron and
semi-structured
interviews with
2 DSWs.
Reports and
Triple C
checklist of
communication.
Reflections by
DSWs
Content analysis of
reflection sheets.
Coding of themes for
the interviews
Videos showed positive
regard for Cameron &
engagement in
techniques, new skill
and location of
interactions.
Reflective logs: shift to
seeing behaviour as
communicative.
Triple C: Cameron’s
communicative skills
increased.
Themes from interviews:
Development of
techniques and skills,
use of teamwork,
seeing things from
Cameron’s perspective,
positive perspective on
II
decrease in negatively
perceived behaviours
10/26
Jones &
Howley 2010
N=5
Age =‘children’
Gender =not stated
Country =UK
Context: children on
To explore the
effectiveness of an
interaction
programme in
schools
Used by: teachers
and support
workers
Training and
support:
Case Study
Approach:
Views collected
from involved
professionals
Codes ascribed to
segments of data
Positive outcomes for
children:
enhanced
communication skills,
development of
15/26
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 11
Table 1 (continued)
Authors and date
Study population (age,
gender and setting) Study objective
Intervention, training
and support Study design Measures/analysis used Outcome/themes reported
Quality
ratings
1
interaction program
who had autistic
spectrum diagnoses
and/or LD. 4 in
mainstream schools
and 1 in special
school
experienced
practitioner
alongside novice.
Intervention: One to
one sessions
gradually
extended to
involve peers
using
questionnaires,
semi-structured
interviews and
document
scrutiny.
Interviews
recorded,
transcribed and
collated.
Questionnaire
given to the
parents of the
child
friendships with peers.
Outcomes for staff:
model perceived to be
effective, increased
staff confidence.
Areas of consideration:
trainees being released
from other work,
availability of suitable
spaces, the importance
of partnerships within
school and with
teachers
Zeedyk et al.
2009a,b
N=12
Gender =9xF, 3xM
Age =16–19,
Country =Romania
Context: practitioners
who used II with 10
girls and 8 boys
with intellectual
disability
To examine the
experience of the
novice
practitioners in II
Used by: novice II
practitioners
Training and
support: 1-h
training session.
Intervention:
1.5 weeks of daily
sessions
Written accounts
of II by the 12
practitioners
Thematic analysis Impact of II on children:
Increase in social
engagement, decrease
in distress and self-
harm, attention to the
wider environment.
Impact of II on
volunteers:
Intensified relationships
with the children,
ineffectiveness, initial
doubts
21/26
1
Quantitative studies rated using SCED scale (Tate et al. 2008); qualitative studies rated using framework from National Institute for Health & Care Excellence (2012).
2
Kellett (2001) study not included in analysis due to being an unpublished PhD thesis.
©2015 John Wiley & Sons Ltd
12 Journal of Applied Research in Intellectual Disabilities
studies (Kellett 2000, 2003, 2004, 2005; Barber 2008;
Samuel et al. 2008) use the approach, first developed by
Nind (1996), which codes for eight indicators of social
behaviour: no interactive behaviours, looking at face,
happy/smiling face, reciprocal social physical contact,
eye contact, joint focus/activity, contingent vocalization
and engaged. The theoretical basis (Nind 1996) adds to
the construct validity of the measures used, and the
clear, operationalized measures have added to
subsequent studies. Measures such as the Pre-Verbal
Communication Schedule (PVCS) and the Sociability
Assessment Scale were also used first by Nind (1993)
and subsequently by other researchers (Kellett 2000,
2003, 2005; Samuel et al. 2008).
Nind’s study (1996) was a multiple-baseline design
with six adult participants. The results appear to show
that all participants improved on measures of sociability
and communication. Improvements were not always
directly concurrent with the start of the intervention,
casting doubt on the intervention as cause. However,
Nind adduces persuasive arguments for the link; the
participants had long-standing low communicative
abilities, many behaviours occurred for the first time
after the intervention began, and teacher’s logs showed
no extraneous events concurrent with improvements. It
was hypothesized that behaviours which increased later
were developmentally more complex.
The series of studies by Kellett (Kellett 2000, 2003,
2004, 2005) are best looked at as a whole, as they
originally formed a multiple-baseline study (Kellett
2001). This was not included in this review, as it has not
been published in a peer-reviewed journal. Separately,
the studies suffered from an unstable baseline (Kellett
2000) and variability in scores coded during the
intervention period (Kellett 2003, 2004, 2005), thus
limiting the conclusions that can be drawn.
Barber (2008) utilized an AB design, with the baseline
measured 12 months before the intervention point.
The extended duration between baseline and post-
intervention measurement casts doubt on the
responsibility of the intervention for the gains in
sociability. In addition, data from only three of 11
students are reported, with no explanation of the
excluded data. Similarly, Leaning & Watson (2006)
present data from three of five participants. These three
did show improvements on sociability scales, but the
missing data are not accounted for and so could raise
bias issues. Samuel et al. (2008) reported an increase in
social behaviour using the same method of video
coding, but these increases were small (<5% was classed
as a ‘noticeable increase’).
Other papers (Lovell et al. 1998; Leaning & Watson
2006; Zeedyk et al. 2009a,b) use a similar approach of
videoing participants and coded for different
behaviours. Zeedyk summarized the scores into an
overall ‘engagement’ score; this simplifies the analysis,
and makes it easy to see that all participants increased
on ‘Engagement’ over the intervention.
Two papers (Lovell et al. 1998; Elgie & Maguire
2001) video-coded similar measures of sociability, but
added idiographic measures of social behaviour.
Lovell et al. (1998) found that ‘putting clothes over
face’ did not decrease following intervention, whereas
Elgie & Maguire (2001) found an increase in
incidences of hand contact which was highly
significant for the client in their study. Although this
was an AB design, the concurrent validity is
strengthened by a 6-month baseline at zero before the
intervention commenced.
Argyropoulou & Papoudi (2012) measured a child
and a peer’s ‘initiations’ of interactions and subsequent
responses. Their use of an ABA design, and the
concurrent increase and decrease of the child’s
initiations with the introduction and withdrawal of the
intervention, provides strong support for the
intervention being responsible for increasing the amount
of initiations. The positive responses of both children
did not decrease following withdrawal, limiting the
extent to which the increase in positive responses can be
objectively linked to the intervention. The authors posit
that the increased positive responses were maintained
due to the relationship that the children had built up
over the sessions.
In the qualitative papers reviewed, all three found
social interaction related themes and sociability was
perceived to be enhanced by the Intensive Interaction
practitioners. However, validity was limited in two
studies (Forster & Taylor 2006; Jones & Howley 2010) by
a lack of clear methodology.
Any conclusions 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 Intensive Interaction may help
to develop communicative abilities; however, the
limitations of the studies prevent firm conclusions being
drawn.
Repetitive behaviours
Jones & Williams (1998) used an approach labelled as
Intensive Interaction to attempt to reduce the repetitive
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 13
hand movements of a man with PMID. The intervention
had no effect on the movements but appeared to utilize
only one of the principles of Intensive Interaction that of
imitation. It did not focus on the reciprocal
‘conversations’ because posited to be important. This
study has been criticized for its blinkered focus on
reducing stereotypy by Nind & Kellett (2002). A more
complex understanding of repetitive behaviours has
been proposed (Kennedy et al. 2000), which includes
taking into account their functions for the person and
criticizes interventions which seek to simply reduce
such behaviours.
In their paper, examining the effect Intensive
Interaction has on repetitive behaviours, Nind & Kellett
(2002) discussed the reduction in stereotypy in six of the
10 participants. The causal relationship between
Intensive Interaction and the reduction was supported
by the use of two multiple-baseline studies. The
reductions in repetitive behaviour are explained as the
participants choosing to spend time in other-directed
rather than self-directed activity. Nind & Kellett (2002)
also highlight a change in the quality rather than
quantity of the stereotypy for some participants where
the decrease was less marked. The clarity of reporting
and data analysis suffered in this paper due to its focus
being a discussion of the challenges and considerations
around stereotypy, rather than a presentation of new
data.
The studies above provide limited evidence to suggest
that Intensive Interaction results in a reduction or
change in quality of stereotyped behaviours.
Self-injurious behaviour
One study has examined an attempt to reduce self-
injurious behaviour using Intensive Interaction (Elgie &
Maguire 2001) This study found no evidence that an
Intensive Interaction intervention affected self-injurious
behaviour. The woman who participated in displayed
self-injurious behaviours, so severe and chronic that
she spent most of her time in arm splints. The
chronicity of the self-injurious behaviour may have
impacted on the capacity of the intervention to effect
lasting change.
In the qualitative study by Zeedyk et al. (2009a,b),
eight of the 12 volunteer practitioners wrote about the
reduction in distress and self-harm they perceived in
the children they worked with, and seven of the 18
children were mentioned. The validity is well
evidenced by quotations and clearly documented
analysis.
In summary, there is, at present, limited support for a
reduction in self-injurious behaviour following Intensive
Interaction interventions.
Staff experience
Some studies reported that perceptions or the support
of staff affected the implementation of Intensive
Interaction interventions (Kellett 2003; Samuel et al.
2008; Zeedyk et al. 2009a,b; Jones & Howley 2010).
Samuel et al. (2008) reported the use of reflective logs
and a support group declined over time and suggested
that this limited changes in staff behaviour and
therefore the clients’ social behaviour. Kellett (2003)
found that staffing factors, such as restricted time and
support, limited the efficacy of the intervention. Zeedyk
et al. (2009a,b) study highlighted practitioners’ struggles
with Intensive Interaction, as themes included
‘ineffectiveness’ and ‘initial doubts’. This may be the
case with all novel techniques and, in this study, was
counter-balanced by the benefits seen for the children
that they worked with.
Anecdotal evidence
The conclusions that could be drawn from the evidence
presented were limited in scope and did not seem to
reflect the positive effects reported to result from
Intensive Interaction. Authors often included moving
descriptions of participants’ interactions, such as, He
seemed happy, as he was laughing and jumping out of joy,
whilst being with the other children (Argyropoulou &
Papoudi 2012, p. 110). Kellett stated, [the child’s mother]
described the joy of the family in finally being able to
‘connect’ with Catherine and wrote that those last few
months were their happiest times together. (2005, p. 119).
However, in a systematic review, these anecdotal
reports are considered ‘insufficient evidence’, and books
and dissertations are excluded due to the lack of peer
reviewing. Despite this, the practice of Intensive
Interaction is growing, and there is a conference every
year discussing pitfalls and successes.
Sustainability of interventions
In several of the studies (Nind &Kellett, 2002; Kellett
2004; Leaning & Watson 2006), there was variability in
the data attributed to disruption in the intervention.
This may have been illness (Kellett 2001), lack of
support for the approach (Kellett, 2002) or cancellation
of sessions (Leaning & Watson 2006), but overall, this
©2015 John Wiley & Sons Ltd
14 Journal of Applied Research in Intellectual Disabilities
shows the importance of having a consistent approach
when using an intervention with such a relational
component.
Conclusions
The aim of this review was to examine the
effectiveness of using Intensive Interaction with people
with intellectual disabilities or autism. The papers
reviewed found that studies examined the effects of
using Intensive Interaction on social interaction,
stereotyped behaviour and self-injurious behaviour.
Unfortunately, the limitations of the methodology and
design of the studies, along with the small numbers of
participants, prevent any conclusions from being made
regarding the effects of Intensive Interaction. The
limited empirical evidence does not appear to fully
support the powerful claims made by authors and
the anecdotal reports of people conducting the
interventions. There may be several reasons for this,
not least the difficulty in conducting good quality,
methodologically and ethically sound research with
people with intellectual disabilities. Such difficulties are
discussed in Kellett & Nind’s paper (2001); this
highlights issues around research design, informed
consent, duration of baseline, tools of measurement
and data ownership. People who are unable to
advocate for themselves need stringent ethical
frameworks to ensure their needs remain paramount.
This often precludes any design where there is a
withdrawing or denial of treatment, such as those that
use a control group or ABA designs.
One of the studies in this review (Lovell et al. 1998)
did utilize an alternating treatments design, where
5 min of Intensive Interaction was followed by a break,
then a ‘proximity’ intervention. The ethics of providing
such an intervention for the purposes of research are
problematic: the research design has parallels to the
‘still face’ paradigm, whereby babies react with distress
to a temporarily unresponsive care giver (Adamson &
Frick 2003); however, whereas the still face paradigm is
a time-limited and one-off procedure, the studies
utilized the two different interventions repeatedly over
a few days. An intervention such as this could be at
best confusing and at worst, distressing, to some of the
most vulnerable research participants.
Several papers in the sample devoted a significant
portion of their thinking to the ethical and conceptual
issues of working with people with PMID or autism
(Nind 1999; Nind & Kellett 2002). This may have been
one of the reasons why their scores on the methodological
reporting of the study were lowered. Such discussions
included an exploration of the adaptive meaning of
‘stereotyped behaviour’, and its use as a communicative
tool for people with intellectual disabilities. At the time it
was published, the understanding of such behaviour was
limited, and thus, such exploration would have been
valued highly as contributing to the knowledge base and
moving it forward.
Another reason why the studies are limited in the
quality of the methodology is the nature of Intensive
Interaction: like many interventions, it is complex and
multifaceted, thus making it difficult to separate the
components and conduct a multiple-baseline design
based on intervention components. The nature of
Intensive Interaction also makes it difficult to use ABA
designs, as the first intervention session may lead to
lasting change. This is seen in Argyropoulou &
Papoudi’s study (2012) where the two participants had
built up a relationship that appeared to have positive
effects on their social behaviour even when the
intervention was withdrawn.
Another issue when researching into interventions for
people with PMID is the heterogeneity of such a
population group. The diversity of participants and
their reactions to interventions means that homogenous
control groups would be near impossible to construct.
Tools of measurement in these studies included video
coding of social behaviours. In a relation approach such
as Intensive Interaction, these seem reductionist.
Methods of assessing the interactions of people with
PMID as suggested by Hostyn et al. (2011) may be more
appropriate. Capturing the rich anecdotal evidence
woven throughout the studies in this area may be
possible using qualitative analysis of the papers; this
may be a direction for future research.
With the research limited by the considerations above,
it is even more important for future researchers to
carefully consider and justify study methodology. For
single case designs, referring to guidance such as Tate
et al. (2008) and Smith (2012) will add to the quality and
strength of research evidence. Qualitative research
should consider standards and rigour, as discussed by
NICE (2012), to add richness and validity to conclusions
drawn.
When training staff in Intensive Interaction, it would
be prudent to encourage them to gather individual
evidence supporting practice, as the published evidence
base is scant. More research needs to be performed
on length of training needed, requirements for staff
support and expected outcomes at different stages of
interventions.
©2015 John Wiley & Sons Ltd
Journal of Applied Research in Intellectual Disabilities 15
Critique
Authors were not contacted to ascertain further
information about the studies that they conducted, such
as their ethical procedures or interview schedules as the
focus was also on reporting quality, essential for effective
dissemination. This may, however, have resulted in
studies being quality-rated unduly harshly. The quality
assessments used (Tate et al. 2008; National Institute for
Health & Care Excellence 2012) can be seen as a strength
of the paper as they were both recognized measures, and
the inter-rater reliability was good. Another consideration
is that papers examined were limited to those published
in peer-reviewed journals; further studies have been
published as PhD theses or in books, including six books
and four theses (Intensive Interaction Institute 2014).
Limiting to peer-review journals does assure a degree of
quality and is common practice in systematic literature
reviews, yet may result in the dismissal of illuminating
research. Further reviews may want to assess the
evidence found in such sources.
Summary
Because the studies have such clear limitations, it is
still not possible to conclude whether Intensive
Interaction is likely to be a helpful intervention for
people with PMID or autism. Unfortunately, no clear
guidance for length or scope of Intensive Interaction
training can be ascertained from this review, as
training was not consistent or not reported. Some
evidence for positive effects on practice did appear to
come from training sessions as short as 1 h, but the
intervention period was just 2 weeks, leaving no time
for such processes as initiative decay (Buchanan et al.
1999), where positive change in practice reduces over
time. A qualitative study of staff experience using
Intensive Interaction suggests that this may occur (Firth
et al. 2008). Based on the studies examined here, there
may be several ways of increasing the effectiveness of
the approach. Those include a team based approach
and support, as purported to be helpful in Barber’s
(2008) study and the lack of which found to provide a
barrier for Kellett (2003) and Samuel et al. (2008).
Wider literature (Culham 2004; Firth et al. 2008)
explores staff concerns about the approach. Staff
support and in-depth exploration of difficult issues
should therefore be a component of any Intensive
Interaction intervention.
It would be beneficial if the perceived positive effects
of Intensive Interaction could be captured in some way.
To provide Intensive Interaction 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.
Correspondence
Any correspondence should be directed to Anna
Bodicoat, Department of Psychological Health and
Wellbeing, University of Hull, East Riding of Yorkshire,
Hull HU6 7RX, UK (e-mail: anna.bodicoat@gmail.com).
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18 Journal of Applied Research in Intellectual Disabilities
