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Mental Health and Learning Disabilities
Research and Practice
Volume 3Number 1
April 2006
With all of us in mind
53
Intensive Interaction: a Research Review
Graham Firth1
1Leeds Mental Health Teaching NHS Trust
Mental Health and Learning Disabilities Research and Practice, 2006, 3, 53 - 63
54
Intensive Interaction – a Research Review
Graham Firth
Abstract
Intensive Interaction is a socially interactive approach to supporting and
developing the pre-verbal communication and sociability of people with
severe or profound learning disabilities, or severe autism. Developed in the
1980’s from the psychological model of ‘augmented mothering’ the
approach currently has an increasing number of proponents who make
claims for increased social responsiveness due to the use of the approach.
This short paper aims to evaluate some of the evidential claims of
consequential increased social responses from people with severe and
profound and multiple learning disabilities due to the use of Intensive
Interaction techniques. Thus the paper presents a review of findings
presented in relevant research papers which have been published in
generally recognised academic journals.
From this review the author concludes that although expanding, the current
body of research has been limited in scope and scale, and has generally
been conducted by a small number of Intensive Interaction practitioners
and advocates. However, increased client social responsiveness was
consistently reported across the research projects reviewed.
In conclusion, this paper advocates for further systematic research into the
approach by the wider research community to further develop the evidential
base of the approach.
Key words: intensive interaction, learning disabilities, research review.
Intensive Interaction: a Research Review
According to the British Institute of Learning Disabilities (BILD) Intensive
Interaction is:
‘… a practical approach to interacting with people with learning
disabilities who do not find it easy communicating or being social….’
(accessed at www.bild.org.uk/factsheets/intensive_interaction.htm on
16/02/06).
Intensive Interaction was originally developed in the 1980’s and was
described by teachers Dave Hewett and Melanie Nind in ‘Access to
Communication: Developing the basics of communication with people with
severe learning difficulties through Intensive Interaction’ (1994). Eschewing
the prevalent behaviourally inspired pedagogy and skill analysis model of
curriculum formulation that prioritised self-help or independent living skills,
Intensive Interaction instead aimed to facilitate the acquisition of
fundamental communication skills and sociability of people with severe or
profound and multiple learning difficulties (it has also been used with
people with severe Autistic Spectrum Disorder). The approach was built on
the concept of ‘Augmented Mothering’ developed by psychologist Gary
Graham Firth
55
Ephraim (1982), who argued for the use of naturalistic interactions with
learning disabled clients based on ‘infant-caregiver’ interactional
techniques.
The techniques of Intensive Interaction include the use of non-task
associated physical proximity, responsive eye contact and facial signalling,
physical contact, vocal echoing and behavioural mirroring. According to
Hewett and Nind (1998),
‘Intensive Interaction is characterised by regular, frequent
interactions between the practitioner … and individual with learning
disabilities, in which there is no task or outcome focus, but in which
the primary concern is the quality of the interaction itself’ (p.2).
During the interactions the practitioner endeavours to follow the client’s
lead, thus responding contingently to their behaviour or activities to create a
joint focus and increased social acknowledgement and interpersonal
signalling (this generally being non-verbal in nature).
With increased use and advocacy across disciplines (e.g. teaching, speech
& language therapy, psychology, social care), Intensive Interaction is now
seen more widely as a way of teaching fundamental communication, as a
means of relationship building, or simply as a way of spending time with
people who are remote or find difficulty in being social.
This article concerns itself with published research papers that are clearly
focussed on the social responses of the learning disabled person to the
approach. Appropriate papers for inclusion were identified by initially
accessing a published list of specific Intensive Interaction research articles
(via www.intensiveinteraction.co.uk ) combined with a process of actively
following a reference trail through the appropriate papers. Specific papers
were then selected to include papers from differing researchers or research
teams, and to accommodate articles from a breadth of learning disability
and special educational journals. Due to the brevity of this article only six
papers are summarized below; three are studies that were carried out with
adult participants and three with children.
Research with Adults Participants
The three papers briefly discussed below (Nind, 1996; Lovell, Jones and
Ephraim, 1998; Elgie and Maguire, 2001) employ varying methodologies,
and were carried out in different settings: an adult special educational
arena; a long-stay residential hospital; and a small group home. However,
across the studies there emerge the common themes of increased or novel
interactive responses by the research participants with severe or profound
and multiple learning disabilities. Collectively the papers’ findings include
increased frequency of social contact demonstrated through raised levels of
contingent smiling, enhanced use of socially significant physical contact,
raised levels of joint attention, and increased use of vocalisation.
In Nind’s (1996) research
(‘Efficacy of Intensive Interaction: developing
sociability and communication in people with severe and complex learning
difficulties using an approach based on caregiver - infant interaction’)
six
adult students with severe and complex learning difficulties, who attended a
Intensive Interaction: a Research Review
56
school within the grounds of a long stay residential hospital, were engaged
with an Intensive Interaction intervention.
This research employed a ‘multiple-baseline interrupted time series
methodology’. Thus the students’ interactional behaviour was recorded
during both a ‘base-line phase’ (of up to six months) and an ‘intervention
phase’ with daily sessions of Intensive Interaction (lasting up to 18 months).
Data was generated by employing video analysis and a number of
observation schedules, including the
Pre-Verbal Communication Schedule
(Kieran and Reid, 1987).
As a result of the Intensive Interaction, the researcher claimed that each
student developed new interactive behaviour, such as ‘contingent smiling’,
‘maintaining a state of joint focus’ or ‘contingent vocalisation’. More
generally all of the students made advances in their communication abilities
as measured on the
Pre-Verbal Communication Schedule
, with progress
noted particularly in the areas of vocal imitation, communication through
gesture, and communication through the use of sounds. According to the
author, there were no significant events concurrent with the onset of the
Intensive Interaction intervention, and therefore no rival explanations for the
developments.
A study by Lovell, Jones, and Ephraim (1998)
(‘The Effect of Intensive
Interaction on the Sociability of a Man with Severe Intellectual Disabilities’
)
investigated the use of Intensive Interaction with a socially withdrawn, 53-
year-old man with severe intellectual disabilities who lived within a large
residential hospital. The client was observed in two differing social
scenarios: in one, a clinical psychologist engaged him with Intensive
Interaction; in the second, the same psychologist remained close to the
client but did not interact with him (these were termed ‘proximity sessions’).
Comparative observational data was gathered from each session using ‘10
second momentary time sampling’ of video-recordings. The same method
had previously been employed to gain base-line observations of the client
in his normal environment, where he was usually observed to be sitting
alone in a corner.
The findings of this research claimed to indicate that during the Intensive
Interaction sessions the client initiated much more physical contact than
prior to the intervention, when it was never evidenced. There were also
claims for more physical contact during the Intensive Interaction than in the
‘proximity sessions’, where it was only occasionally observed. Also
indicated was an increased time spent ‘looking at people’ during Intensive
Interaction, and doing so with more consistency than in the ‘proximity
sessions’. No episodes of joint attention were recorded prior to the
interventions and just one instance was recorded in the ‘proximity
sessions’. However, the client demonstrated many episodes of joint
attention during the Intensive Interaction sessions.
The authors also claimed that there were additional benefits to the use of
Intensive Interaction in terms of changes in the client’s mood. The client
was observed to smile, laugh and vocalise more in the Intensive Interaction
sessions than prior to the interventions, when no examples of these
responses were recorded. However, due to an unrelated injury to the client,
this research endeavour had to be prematurely curtailed and so the findings
should be judged as incomplete.
Graham Firth
57
A study by Elgie and Maguire (2001) (‘
Intensive Interaction with a Woman
with Multiple and Profound Disabilities; a case study’
) reported on the use
of Intensive Interaction with an extremely socially withdrawn woman with
profound learning disabilities. This lady had engaged, since childhood, in
serious self-injurious behaviour which damaged her face and eyes, and she
was therefore blind. She had no verbal skills and was reported as using
only very limited non-verbal communication.
After base-line measurements, a 16 week Intensive Interaction intervention
was employed using physical contact (especially hand holding), vocal
commentary with intonation, and sensitively timed vocal imitation.
According to the authors, one result of this intervention was increased
spontaneous hand contact, which contrasted with the client’s previous
behaviour when no spontaneous reaching out had been observed. The
authors also reported evidence of increased vocalisations during the
Intensive Interaction sessions, as compared to when the lady was alone.
Somewhat disappointingly from the authors’ perspective, there was no
appreciable change observed in the level of the client’s self injurious
behaviour over time. However, the authors claimed that this was to be
expected at such an early stage of the Intensive Interaction intervention.
Research with Child Participants
The claims made as a result of research into the responses of children to
Intensive Interaction are similar to those for adults, with claims for
increased social responsiveness. However, again it should be
acknowledged that the body of research is not large.
The three papers summarised below were all carried out in an educational
setting and employed varying methodologies. Again, common themes
emerged indicating increased levels of joint attention, active participation
and turn taking. However, one potentially important factor for research in
this area is the consideration that children’s development could be
accounted for by a process of general maturation rather than any specific
intervention. Therefore any causal links identified on the basis of evidence
generated in this area should always be judged with this in mind.
One study into children’s responses, carried out by Watson and Knight
((1991) ‘
An Evaluation of Intensive Interactive Teaching with Pupils with
Very Severe Learning Difficulties’
) explored the use of Intensive Interaction
with six pupils with severe learning difficulties at a special school in
Scotland. The children’s responses were studied over a whole school year.
Six members of staff worked consistently with the same child, and used
toys or objects to generate interactive games. Evidence was gathered
using video recordings, contemporaneous staff records and interviews with
staff members.
From this study the researchers claimed that staff-pupil pairs built up
individual interaction styles that created potentially enabling changes in the
children’s social behaviour. Such developments for individual children
included increased levels of alertness; increased instances of eye contact;
increased turn taking and sharing of objects; increased socially significant
Intensive Interaction: a Research Review
58
vocalisations; increased active participation; and for one child, indications
of improved gross motor control.
More subjectively, but perhaps equally as important, the staff emphasised
that they believed that Intensive Interaction enabled the development of
good pupil-staff relationships. The staff members also indicated other
effects of Intensive Interaction as significant from their own perspective,
including staff being more relaxed, tolerant and willing to wait for the
children’s responses.
With a view to generating more comparative data, Watson and Fisher
((1997)
Evaluating the Effectiveness of Intensive Interaction Teaching with
Pupils with Profound and Complex Learning Disabilities
) evaluated two
teaching methods, teacher-directed activity and Intensive Interaction, over
a nine-month period, for pupils with very severe learning difficulties and
multiple impairments. From Pre-verbal Communication Schedule
assessments (Kiernan and Reid, 1987) and data from sessional
videotapes, the authors claimed that there were some ‘striking’ examples of
social or communicative behaviours evidenced during sessions of Intensive
Interaction. It was also claimed that these behaviours were not observed
during other, more didactic classroom activities. There was evidence of
increased movement; the development of turn-taking sequences; and more
pupil initiated activity.
Generally, according to the authors, during the Intensive Interaction
sessions all the pupils ‘demonstrated higher levels of active participation
and enjoyment’. This contrasted with the teacher-directed group activities,
where there was a tendency for pupils to take on the role of ‘passive
recipients’ toward the activities. Based on these observations the authors
concluded that Intensive Interaction was ‘a more rewarding social
experience’ for the pupils, and one ‘in which they showed initiative and
control’.
A single case study by Kellett (2000) (
Sam’s Story: Evaluating Intensive
Interaction in Terms of its Effect on the Social and Communicative ability of
a Young Child with Severe Learning Difficulties
) concerned a five-year-old
boy, Sam, at a community special school (this paper reported on just one
case out of a larger longitudinal study involving six children with severe
learning disabilities). Sam often engaged in self-stimulatory behaviour and
was indicated by the school staff as living ‘in a world of his own’. He did not
use any symbolic language or formal signs, made no eye contact with other
people, and appeared not to observe nor respond to other peoples’ facial
signalling.
The researcher used a ‘multiple-baseline interrupted time series’
methodology, employing systematic video-recorded observation over one
academic year. The observed progress made by Sam after the initiation of
daily 10 minute sessions of Intensive Interaction was identified as:
! ‘Modest progress’ in the incidence of ‘social physical contact’
! ‘Clearly evident’ progression for Sam in the incidence of ‘eye contact’
! ‘Huge steps’ forward in ‘looking at or towards a partner’s face’
! Sam’s ability or willingness to engage in joint focus or joint activity with
the teacher ‘developed dramatically’
Graham Firth
59
! Sam beginning ‘to use his vocalising ability to respond contingently and
to initiate contact’
It should be noted that the often emotive terminology used by the author in
this paper stands in contrast to the more generally accepted scientific or
quantitative vernacular. However, the author also wisely cautions against
over-generalisation from such a single case study, identifying this paper as
adding to the body of consistently reported increases in social
responsiveness associated with the adoption of Intensive Interaction
techniques.
Discussion
For pragmatic reasons such a brief paper as this has a limited scope, and
therefore cannot claim to give a comprehensive view across all current
research into Intensive Interaction. However, the body of evidence arising
from the research papers reviewed in this article appears consistently
supportive of claims of increased social responses from the research
participants associated with the onset of Intensive Interaction interventions.
There are repeated claims of novel or increased socially interactive
behaviours manifest through greater use of eye contact; increased
toleration of, or engagement in, physical contact activities; additional
episodes of sustained joint attention; increased use of potentially
communicative vocalisations; and an increased regard for facial signalling.
There is also evidence of greater initiation of social interaction by some of
the research participants.
However, in some aspects the findings from these research endeavours
were not wholly consistent, and due to the different time scales employed
not directly comparable. Nind (1996) makes a claim for reductions in the
levels of the participants’ ritualistic or self-stimulatory behaviours as new
interactive behaviours emerge, whereas in the much shorter case study of
Elgie and Maguire (2001) no significant change in the levels of their client’s
self-injurious behaviour was evidenced.
It could be argued that the body of evidence is still limited in its
generalisabilty due to the methodologies employed, that is the use of small-
scale or single case studies without experimental controls. The limited time
scale of some of the research studies could also be seen as a potential
weakness with respect to the validity of the findings in terms of sustainable
changes to the behaviours measured. It should also be noted that the main
body of research carried out into the use of Intensive Interaction has been
conducted by a relatively small number of practitioners and advocates of
the approach, generally educationalists and clinical psychologists. There is
therefore also an issue of unintentional bias to be considered in the
operationalisation and reporting of studies closely tied to the researchers
own professional endeavours.
Another potential criticism of the body of research concerns the claims
made concerning process. For those papers written from an explicitly
educational perspective (and published in educational journals) there is an
assumption, sometimes explicitly stated, that the novel or increased social
responses arise out of a teaching or learning process, i.e. that there is
specific
social skill acquisition
. The other, non-educational researchers
Intensive Interaction: a Research Review
60
seem to be indicating a much more rapid ‘social inclusion’ model of
increased responsiveness, and indeed these research endeavours were
generally much shorter, with social skill acquisition presumably much less
likely within the given time frames (e.g. 10 or 16 weeks). Such a ‘social
inclusion’ model seems to acknowledge the potential for the client or
students’ latent social skills or behaviour to be increasingly expressed as
increased opportunities are presented to them in a socially inclusive way.
Some consideration within the research literature of cognitive or learning
theory might help elucidate this apparent duality. Indeed some situated
learning theories, e.g. Legitimate Peripheral Participation (Lave and
Wenger, 1991) explicitly view authentic engagement in activities or ‘joint
enterprises’ (in this case social and communicative enterprises) as a
necessary precursor to conceptual development and skill acquisition. Thus,
from such a perspective the educational or social processes underlying
Intensive interaction could be viewed as seamless and phenomenologically
co-dependant. Nevertheless, whatever the view taken on process,
increased interactional activity has been systematically evidenced, but
perhaps future research could benefit from being more conceptually aware
of such a potential duality.
Taken together, despite the possible critiques and the potential for dual
process, the research findings indicated in this review could be viewed as
adding credible support to the case that if social occasions are purposefully
generated in such a way as to facilitate the social participation of people
with severe or profound learning disabilities, then this can lead to increased
social engagement on their part.
Interestingly, despite Intensive Interaction being increasingly reported on,
researched, and even indicated as accepted practice by a number of large
voluntary and government agencies (British Institute of Learning Disabilities
(
ibid
); The Foundation for People with Learning Disabilities (2001, p. 28);
The Qualifications and Curriculum Authority (2001, p.18)) no large scale,
centrally funded research into the approach has as yet been undertaken.
But certainly it is this author’s view that in times which increasingly focus on
and value evidence-based practice, it is vital that further empirical research
takes place to build on the already emergent body of evidence. However,
such research would not only have to ensure robust validity and
generalisability, but would also need to take complete account of the
complexity of human interactional behaviour whilst acknowledging its full
contextual depth.
Valuing People, the Government’s Strategy for Learning Disability policy in
the 21st Century, states that ‘people with learning disabilities are often
socially isolated’ (7:39, p. 81). It also clearly states in Objective 7 that
people should be enabled to ‘…develop a range of friendships, activities
and relationships’ (p. 127). If this objective is to genuinely transpire,
particularly for those people with the most profound and complex learning
disabilities, then further structured investigation into Intensive Interaction as
a potential means for developing such activities, interests and relationships
is undoubtedly required.
Graham Firth
61
References
British Institute of Learning Disabilities 2005 on-line at www.bild.org.uk:
www.bild.org.uk/factsheets/intensive_interaction.htm (accessed 2/07/05).
Department of Health 2001. Valuing People: A New Strategy for Learning
Disability for the 21st Century [Cm 5086]. London: The Stationery Office.
Elgie, S. & Maguire, N. 2001. Intensive Interaction with a woman with
multiple and profound disabilities: a case study, Tizard Learning Disability
Review, 6 (3), 18-24.
Ephraim, G. 1982. Developmental processes in mental handicap: a
generative structure approach, Unpublished PhD thesis, Brunel University
Foundation.
Hewett, D. & Nind, M. 1998 (eds) Interaction in Action: reflections on the
use of Intensive Interaction, David Fulton, London.
Kellett, M. 2000. Sam’s story: evaluating Intensive Interaction in terms of its
effect on the social and communicative ability of a young child with severe
learning difficulties, Support for Learning, 15 (4), 165-171.
Kiernan, C. & Reid, B. 1987. Pre-Verbal Communication Schedule. NFER-
Nelson, Windsor.
Lave, J. & Wenger, E. 1991. Situated Learning: Legitimate peripheral
participation, University of Cambridge Press, Cambridge.
Lovell, D., Jones, R. & Ephraim, G. 1998. The effect of intensive interaction
on the sociability of a man with severe intellectual disabilities, The
International Journal of Practical Approaches to Disability, 22 (2/3), 3-8.
Nind, M. & Hewett, D. 1994. Access to Communication: Developing the
basics of communication with people with severe learning difficulties
through Intensive Interaction, David Fulton, London.
Nind, M. 1996. Efficacy of Intensive Interaction: developing sociability and
communication in people with severe and complex learning difficulties
using an approach based on caregiver- infant interaction, The European
Journal of Special Educational Needs, 11 (1), 48-66.
The Qualifications and Curriculum Authority 2001. Planning, teaching and
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guidelines, QCA Publications, London.
The Foundation for People with Learning Disabilities 2001. All About
Autistic Spectrum Disorders, The Mental Health Foundation, London.
Watson J. & Fisher A. 1997. Evaluating the effectiveness of Intensive
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disabilities, The British Journal of Special Education, 24 (2), 80-87.
Intensive Interaction: a Research Review
62
Watson J. & Knight C. 1991. An evaluation of Intensive Interactive teaching
with pupils with very severe learning difficulties, Child Language Teaching
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Graham Firth
