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Training care staff in intensive interactions


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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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December 2013 | Volume 16 | Number 10 LEARNING DISABILITY PRACTICE
Art & science | The synthesis of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON
INTENSIVE INTERACTION is a transactional
approach to developing improved communication
for children and adults who have severe or profound
learning difficulties and/or autism, and who are still
in the early stages of developing communication.
Based on the naturalistic deployment of the socially
interactive strategies adopted during interactions
between infants and caregivers, intensive interaction
can be viewed as ‘a means of communicating with
people that uses their means of communication’
(Kennedy 2001).
Therefore, as practitioners of Intensive
Interaction try to match their communication
means to those of the person they are engaging,
to an outside observer this may well look like the
practitioner is joining in with or mirroring aspects
of the person’s current behaviour (e.g. their physical
activity or body movements) or echoing back some
of their vocalisations (even if these are not properly
formed words).
The approach works by progressively developing
enjoyable and affirming interactive sequences
between intensive interaction practitioners and
people with communication or social impairments.
These interactive sequences are repeated frequently
and increase gradually in duration, complexity and
The approach tends to be adopted for
communication with people who can be described
as ‘difficult to reach’ or who are not motivated
to engage socially with others. These include
people with:
Advanced dementia.
Multi-sensory impairments.
Severe or profound and multiple
learning difficulties.
Intensive interaction focuses on developing
mutually pleasurable social interactions by using the
‘fundamentals of communication’ (Nind and Hewett
2001), which are aspects of communication that
generally precede the development of speech. They
include (Nind and Hewett 2001):
Developing the ability to attend to another
Enjoying being with another person.
Understanding how to share personal space with
other people.
Understanding and making eye contact.
Graham Firth is the intensive
interaction project lead
Charlotte Poyser is a research
psychology intern
Nicola Guthrie is an intensive
interaction project co-ordinator
All at St Mary’s Hospital, Leeds
and York Partnership NHS
Foundation Trust
Date of submission
June 28 2013
Date of acceptance
September 30 2013
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
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.
Autism, communication, intensive interaction, severe
or profound learning difficulties
Graham Firth and colleagues discuss how residential and
day service staff can change how they communicate with
people who have severe or profound learning disabilities
Art & science | The synthesis of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON
December 2013 | Volume 16 | Number 10 LEARNING DISABILITY PRACTICE
Art & science | communication
Understanding and making facial expressions.
Understanding and making socially significant
physical contact.
Vocalising with meaning. For some people, this
involves speech development.
Learning to perform sequences of activity or
taking turns in exchanges with another person.
Intensive interaction sessions should take place
as frequently as possible. Successful activities
should be repeated so that clients’ periods of
social communication and sociability expand
gradually in duration, content and complexity.
Studies of intensive interaction state that it can
produce a number of increased or novel interactive
responses, including:
Social initiation and/or engagement (Nind 1996,
Watson and Fisher 1997, Kellett 2000, 2003,
2004, Cameron and Bell 2001, Anderson 2006,
Barber 2008, Samuel et al 2008, Zeedyk et al
2009a, Zeedyk et al 2009b, Argyropoulou and
Papoudi 2012).
Tolerance of, or responsiveness to, physical
proximity (Nind 1996, Firth et al 2008,
Zeedyk et al 2009a, Zeedyk et al 2009b).
Contingent smiling, or smiling in response
to enjoyable stimuli (Nind 1996, Lovell et al
1998, Leaning and Watson 2006, Barber 2008,
Zeedyk et al 2009a, Argyropoulou and
Papoudi 2012).
Eye contact or willingness to look at another
person’s face (Watson and Knight 1991,
Lovell et al 1998, Nind 1996, Kellett 2000, 2003,
2004, 2005, Cameron and Bell 2001, Leaning
and Watson 2006, Barber 2008, Samuel et al
2008, Zeedyk et al 2009a, Zeedyk et al 2009b,
Argyropoulou and Papoudi 2012).
Vocalisation (Watson and Knight 1991, Lovell et al
1998, Kellett 2000, Cameron and Bell 2001,
Elgie and Maguire 2001, Argyropoulou and
Papoudi 2012).
Socially significant physical contact (Lovell et al
1998, Kellett 2000, 2003, 2004, Elgie and Maguire
2001, Barber 2008, Firth et al 2008, Samuel et al
2008, Argyropoulou and Papoudi 2012).
Joint attention, in which more than one
person focuses on the same object (Nind 1996,
Lovell et al 1998, Kellett 2000, 2003, 2004, 2005,
Leaning and Watson 2006, Samuel et al 2008).
In a study of intensive interaction with individuals
with learning disabilities who present with severe
challenging and/or self-injurious behaviour,
Sharma and Firth (2012) also report reduced
frequencies of such behaviours.
Intensive interaction is now common practice
in many UK special schools and is increasingly
being adopted in adult services. A range of
learning disability professionals, including learning
disability nurses, speech and language therapists,
occupational therapists, and clinical psychologists,
advocate the approach, and it is increasingly studied
at graduate level, on learning disability nursing
and speech and language therapy courses, and on
some postgraduate courses.
Interaction programme
The Leeds NHS intensive interaction programme
was developed in 2010 to ensure that staff at local
residential and day services would be more fully
supported in implementing the approach after
they had received the relevant training. It is run by
Ventures Therapy Services, part of the Leeds and
York Partnership NHS learning disability services
directorate, and is similar to an initial triage system.
Led by the principle author, the intensive
interaction team gathers information from
observations of clients, discussions with their
families and support staff, and completed intensive
interaction screening forms, which comprise series
of questions for care staff about clients’
communication styles.
Box 1 Questions asked of clients’ representatives
1. The questionnaires comprised
ten questions:
2. Did you see any improvements
in the service user during the
training programme?
3. Was intensive interaction
applied during the 12-week
training period?
4. Did you continue with
intensive interaction after
the training programme had
5. Were the DVD and SNAP
still useful after the training
programme had finished?
6. Did the service user’s social
skills improve while intensive
interactions were being applied?
7. Did the service user’s
communication skills improve
while intensive interactions
were being applied?
8. Did the service user’s
challenging and self-injurious
behaviours decrease while
intensive interactions were
being applied?
9. Has intensive interaction
improved the relationship
between service user
and provider?
10. Has the service user benefitted
from intensive interaction?
11. Would you recommend the
Leeds NHS intensive interaction
service to other professionals?
LEARNING DISABILITY PRACTICE December 2013 | Volume 16 | Number 10
Art & science | communication
When enough information has been gathered, the
intensive interaction team, in discussion with the
service management and staff, decide what levels of
intensive interaction intervention would most likely
benefit the service users and providers.
The team provides one of three services:
Management-focused, in which the intensive
interaction team consult staff managers
about specific relevant topics, such as staff
development and supervision.
Staff and management-focused, in which
managers and at least two members of staff
are invited to attend the Leeds NHS intensive
interaction foundation training programme.
This comprises three full-day modules: an
introduction to intensive interaction, intensive
interaction analysis and practice development,
and using intensive interaction recording systems
to support good practice.
Service users, staff and management-focused
intervention, in which two experienced Leeds
NHS intensive interaction practitioners provide a
12-session training programme for clients, carers,
staff and managers. These sessions, which are
usually held on a weekly basis, are about an hour
long, and may be delivered continuously or in
several short bursts, depending on the service
user’s preference. To build trust, staff carried out
sessions with the same service users. The sessions
are video recorded by the intensive interaction
team and a DVD of the edited footage is provided
to participants at the end of the programme.
Staff also receive individualised strengths and
needs plans (SNAPs), which are summaries of
each service user’s interactive strengths and how
to respond to them, and advice about recording
intensive interactions to help identify whether the
service user’s sociability has improved.
Earlier this year, a research psychology intern,
who did not work for Ventures Therapy Services,
evaluated the effectiveness of the intensive
interaction programme. Questionnaires were posted
to the representatives, including a parent, a primary
carer and a service manager, of 37 clients who had
completed the intensive interaction programme.
To preserve respondents’ anonymity, they were asked
not to identify themselves when completing the
questionnaires. The questions are shown in Box 1.
To elicit qualitative responses, space was
provided on the questionnaires for respondents to
comment on each question, describe their overall
experiences of the programme and explain how they
thought it could be improved (Box 2).
Box 2 Examples of qualitative comments include:
Comments on:
Question 1
‘The team has noticed the individual wants to
communicate with staff more. There are fewer
behavioural issues too and the individual’s
frustration has been reduced.’
‘The service user was going through a difficult
time [and exhibited] different behavioural changes.
There were times when she would enjoy or tolerate
the programme, and would calm herself during the
intensive interaction.’
Question 2
‘Intensive interaction was not consistently applied
because the service user was difficult to reach.
Her basic daily support needs were challenging but
have now improved.
Question 3
‘Intensive interaction was continued because
the activities were useful and all residents are
encouraged in this area.’
‘Intensive interaction was already being used but
the Leeds NHS team had new insights into [them].’
‘[Intensive interaction was continued] to give the
individual support and comfort through his anxiety,
and to build relationships between him and the staff.’
Question 8
‘The client now knows she has someone who will
listen to her, and staff value her as a person and
not a problem.’
The programme as a whole
‘This was a positive experience with a huge
learning curve.’
‘This was enjoyable because staff and service users
like the intensive interaction.’
‘Enjoyable for service users, and it built
relationships between staff and tenants.’
‘Insightful and enjoyable.’
‘Enjoyable and positive.’
How the programme could be improved
‘Six-month or even annual reviews could [help
us] to measure progress. It is too easy for staff to
forget the importance and simplicity of intensive
interaction due to other pressures.’
‘More staff getting on [training] sessions.’
‘More regular sessions for service users.’
‘Annual reviews and progress meetings would [help
us] to measure where the person is at and to keep
intensive interaction alive in the minds of staff.’
December 2013 | Volume 16 | Number 10 LEARNING DISABILITY PRACTICE
Art & science | communication
Results and conclusion
Fourteen people returned the questionnaires, giving
a response rate of 38 per cent. Their responses to
the questions are shown in Figures 1 and 2.
All aspects of the intensive interaction
programme received generally positive feedback.
Service users’ social skills, such as their willingness
to initiate social contact, and communication
skills, such as their willingness to engage in joint
attention and use facial expressions, were said
to have improved. A few respondents reported
that the incidence of challenging or self-injurious
behaviour had reduced, but no data on the rates
of such behaviour were collected so this claim is
difficult to evaluate accurately.
Most of the staff who had taken part in the
programme said it had been well prepared, and that
the intensive interaction team provided excellent
support during and after the sessions. They
said that the DVDs and SNAPs were particularly
Figure 2 Responses to questions 5-9
8 -
7 -
6 -
5 -
4 -
3 -
2 -
1 -
0 -
Number of respondents
Yes, a lot
Yes, quite a lot
Yes, somewhat
Yes, a little
Question 5 Question 6 Question 7 Question 8 Question 9
Answers to questions
Figure 1 Responses to questions 1-4 and 10
14 -
13 -
12 -
11 -
10 -
9 -
8 -
7 -
6 -
5 -
4 -
3 -
2 -
1 -
0 -
Number of respondents
Question 1
Answers to questions
Question 2 Question 3 Question 4 Question 10
LEARNING DISABILITY PRACTICE December 2013 | Volume 16 | Number 10
Art & science | communication
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strategies: using video analysis to support
teachers working with preverbal pupils. British
Journal of Special Education. 33, 3, 114-120.
Argyropoulou Z, Papoudi D (2012) The training
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Kellett M (2003) Jacob’s journey: developing
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Kennedy A (2001) Intensive interaction.
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useful in helping them develop their own intensive
interactions. Almost all staff said that they were
continuing to engage in intensive interactions with
service users. This is an important finding because,
when staff who have not taken part in full training
programmes try to engage in such interventions,
they tend to abandon them after their novelty has
passed (NHS Modernisation Agency 2003) in a
process known as ‘initiative decay’ (Buchanan et al
1999).Perhaps most pleasingly, every one of the
14 services that replied said they would recommend
the programme to other professionals.
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... Adaptive Interaction (AI: Astell, 2011, 2017) is one such approach to communicating with people living with dementia who can no longer speak. AI was developed from Intensive Interaction (Hewett, 1996;Hewett, 2011;Nind, 1996), a teaching/learning approach developed in the UK in the 1980s for people considered "difficult to reach" (Firth et al., 2013). Specifically, these are children and adults with profound and multiple intellectual disabilities who do not develop speech. ...
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Caregivers find it difficult to interact with people with dementia who have lost the capacity for speech. Adaptive Interaction is a simplified approach that uses the nonverbal fundamentals of communication to connect with people who can no longer speak. Here we present Adaptive Interaction as a method for equipping caregivers with these nonverbal skills to increase communication with the people they care for. Six caregivers were each paired with one individual with dementia and trained in Adaptive Interaction. After receiving training in Adaptive Interaction, caregivers identified more communicative behaviours in their interactions partners and engaged in more frequent positive social behaviours and meaningful actions during interactions. These findings suggest that it is possible to equip staff to use simplified communication based on nonverbal fundamentals to connect with people with dementia who can no longer speak.
... While the authors generated a number of issues associated with the implementation of II, of particular note were philosophical obstacles of age appropriateness, public image of the clients and 'initiative decay', where the novelty of the approach wears off. Interestingly, an evaluation of the Leeds NHS II Programme (Firth et al. 2013) received particularly positive feedback from staff regarding post-training tools, a DVD compilation of footage from the staff training sessions and client summaries of communication skills, implemented in an attempt to combat decay. ...
Background: Intensive interaction (II) is a communication approach useful for working with people with severe intellectual disabilities. Health and social care providers offer II training courses to paid carers working in local services with the goal of improving social communication for their clients. Materials and methods: Eight paid carers who had been trained in II were interviewed 2-3 years after training, to explore how their practice had changed, and whether any changes were sustainable. Interviews were analysed using interpretative phenomenological analysis. Results: Analysis revealed a master theme of emotional and practical endurance, with empowerment, better understanding and perceived barriers to implementation comprising subthemes. Conclusions: Despite actual and perceived barriers to the enduring use of II, all participants spoke positively of the approach and were continuing to use II in practice.
Background Intensive interaction is an approach used to develop the communication and social inclusion of those who are pre‐verbal. It is used in a variety of settings by healthcare and educational staff. Method A systematic search was conducted to identify and review the literature which explores staff experiences of intensive interaction being implemented within their places of work. Thematic synthesis was utilized to synthesize the findings. Results Nine papers were included. Three higher‐order themes were generated: “Personal Doubt, Discordance & Discomfort,” “A Turning Point” and “Needing Implementation at All Levels.” Conclusions There were consistent findings across a range of settings. Findings suggest that intensive interaction is rewarding for staff and beneficial to those that they work with. Implementation was sometimes perceived to be challenging and this review attempts to highlight solutions with guidance of the literature. Limitations largely relate to heterogeneity of the papers and methodological limitations are discussed.
Full-text available
The purpose of this study was to examine the effectiveness of intensive interaction during interactive play between a preschool boy with autism and his teacher and, as a consequence, improve the social interaction between the boy and a non-autistic girl in an inclusive class in Greece. A single subject ABA design was applied. Observed variables included changes in the frequency of initiations and responses of the two children. Results indicated significant improvement and post-training maintenance in the social interaction of the two children. Discussion of results in light of known research in autism is highlighted and implications are discussed.
Full-text available
Intensive Interaction was introduced to a special developmental school in Melbourne, Australia. The school had previously used behavioural and skills‐based teaching approaches to underpin the teaching of students with severe/profound intellectual disabilities and autistic spectrum disorders. Video baselines of students involved in classroom interactions were taken before introducing the approach of Intensive Interaction to the school. Following a 30‐week period during which the approach was practised routinely in classrooms, further video records were made. These video records enabled comparison to be made against five indicators of student involvement. Professional development using video techniques and structured reflection was initiated with all involved staff. Increases in the student’s joint focus, positive affect and interactive involvement were noted. In addition to changes in the communicative involvement of the pupils, the practitioner’s communicative involvement was also noted to change.
Full-text available
Background Intensive Interaction is an approach to developing the pre-verbal communication and sociability of people with severe or profound and multiple learning disabilities and autism. Previous research has indicated many potential benefits; however, the approach is not consistently used in social care.Aim To report on the significant and influential issues for care staff when adopting Intensive Interaction as a novel approach in the social care setting for clients with profound and multiple learning disabilities.Materials and Methods Twenty-nine care staff from four residential settings were trained and supported in the use of Intensive Interaction over a 6-month period. Interviews with staff members and researcher field-notes were analysed using a Grounded Theory methodology.Results and Conclusions Increased and novel client responses were reported which were consistent with previous research. However, some practical and philosophical difficulties were highlighted by staff regarding their adoption of the approach. Consideration of care staff's experiences and perspective could enable future Intensive Interaction interventions to be more successfully planned and supported.
Intensive interaction (II) recognises the pre-verbal nature of adults with profound learning disabilities and mimics the early attachment process to develop the very beginnings of communication and sociability. This paper Reports on the use of II with a remote and withdrawn adult with severe learning disabilities and visual impairments, who engaged in serious self-injurious behaviour. The results indicate that the intervention was successful in facilitating the development of the first stages of social and communication skills.
Intensive Interaction was developed as a teaching approach for students who experienced severe difficulties in learning and in relating to others. The approach recognizes the pre‐verbal nature of the learners and addresses their need to develop the very beginnings of sociability and communication. Intensive Interaction is based on the process of caregiver‐infant interaction in which the first stages of sociability and communication develop. This paper summarizes the first major study of Intensive Interaction which investigated whether it could similarly facilitate this fundamental social and communication development in the target group of people with severe developmental disabilities who demonstrated ritualistic behaviours. A multiple baseline across subjects interrupted time‐series design was employed and the six subjects were all residents of a long‐stay hospital. The measures included real‐time observation schedules, video analysis, Kiernan and Reid's Pre‐Verbal Communication Schedule and an adaptation of Brazelton's Cuddliness Scale. Results showed improved pre‐communication and informal communication abilities, ‘cuddliness’ and ability to maintain and initiate social contact, and a trend towards reduction in ritualistic behaviour.
Within the special needs field, interactive interventions are gaining attention as a means of promoting social engagement for individuals with communicative impairments. The present paper examined the experiences of practitioners of one such approach, Intensive Interaction (II), by analysing written reflections provided by 12 newly trained practitioners. Their insights are particularly interesting because they were working in a voluntary capacity with a novel population: Romanian children living in state care, whose communicative impairments have been complicated by a history of neglect. A thematic analysis indicated that one hour’s training in II was sufficient for (i) enabling trainees to identify key changes in children’s engagement (e.g. increased attention to partner, decreased distress) and (ii) strengthening trainees’ sense of connection to the children. If such brief training sessions are effective in improving communicative interactions, this offers benefits to health and education service providers seeking to implement communicative intervention programmes. While interactive approaches have potential in all regions, they may be particularly valuable in countries such as Romania, which face monumental financial challenges in improving standards of childcare.
Judith Watson, lecturer and Anne Fisher, teacher, present encouraging results from two research studies which evaluated the effectiveness of Intensive Interactive teaching with pupils who had profound and complex learning difficulties. The method is compared with the effects of other classroom experiences over the course of one school year.
Sam’s story began a little over a year ago, when he participated in a longitudinal research project to evaluate the efficacy of Intensive Interaction on the sociability and communication abilities of young children with severe and complex learning difficulties (SLD). The project spanned an academic year and involved six SLD children in two community special schools and one nursery. Significant levels of social and communicative progress were made.
This paper describes the use of a new project, ‘from the inside looking out’ (FILO) (N. Richardson Unpublished data), to develop communication, interaction and emotional literacy skills with people with profound and multiple learning disabilities. The authors utilized tools derived from Intensive Interaction Therapy [D. Hewett & M. Nind (1994)Access to communication. London, David Fulton Publishers; D. Hewett & M. Nind (1998)Interaction in action: reflections on the use of Intensive Interaction. London, David Fulton Publishers] and applied these within a FILO paradigm to run an 8-week group with five participants where the aim was to build relationships and enhance awareness of emotional variables. The results were measured using both quantitative and qualitative analysis and it was found that a number of discreet observable behaviours related to interactive ability were positively changed across all participants. Important processes within the group are analysed and recommendations for expanding this approach in the future are discussed.
Carolyn Anderson is a speech and language therapist who is currently working as a senior lecturer at the University of Strathclyde. In this article she provides an early account of her ongoing research into communication between teachers and pupils with severe and complex learning disabilities. Video recordings were made of teacher-pupil interactions. The recordings were then analysed in terms of the numbers of turns taken by pupils and teachers; the strategies teachers and pupils used to initiate and respond in interactions; and the numbers of information carrying words teachers used with pupils with different levels of language comprehension. Carolyn Anderson's findings will help teachers who want to develop their own awareness of the role they play in communicating with pupils. This research will also support staff who are trying to encourage pupils with learning difficulties to become more actively involved in interactions and teaching and learning opportunities.