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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
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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
sophistication.
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.
Autism.
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
person.
Enjoying being with another person.
Understanding how to share personal space with
other people.
Understanding and making eye contact.
Correspondence
graham.firth@nhs.net
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
ldp.rcnpublishing.com
Abstract
Intensive interaction is a way of improving
communication with children and adults who
have severe or profound learning disabilities and/
or autism. Research shows intensive interaction
interventions often lead to more or new responses.
This article discusses the Leeds NHS intensive
interaction programme, which was developed to
help staff implement the approach with individual
service users. It also describes an evaluation of the
programme during which feedback was generally
positive and respondents said they would recommend
the programme to other services.
Keywords
Autism, communication, intensive interaction, severe
or profound learning difficulties
TRAINING CARE STAFF IN
INTENSIVE INTERACTIONS
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
TRAINING CARE STAFF IN
INTENSIVE INTERACTIONS
Alamy
December 2013 | Volume 16 | Number 10 LEARNING DISABILITY PRACTICE
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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
finished?
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?
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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.
Evaluation
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.’
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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
No
Other
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
Yes
No
Other
Question 1
Answers to questions
Question 2 Question 3 Question 4 Question 10
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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. ...
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