These notes provide a reminder of the nature and scope of Intensive Interaction as an intervention to engage individuals with learning disability and/or autism, and to promote communication and the establishment of a reciprocal relationship.
The background is described followed by a selection of evaluative findings which suggest the usefulness of this approach, perhaps particularly as one component of a programme of strategies for use in a range of settings.
M.J. Connor October 2005
Work in the field of establishing contact and communication with individuals who experience (severe) learning difficulties, or a degree of autism towards the lower functioning end of the spectrum, has been developed by David Hewett and Melanie Nind who met as members of staff at a specialist school sited on the campus of a long stay hospital.
Their theory and practice is set out in a number of publications, such as Nind and Hewett (1994), and the basic background to Intensive Interaction is described by Hewett (2005) in the preface to his document about courses and consultation services.
He begins by referring to the observably wide range of needs among the young people in his class at the school where he completed his early teaching work.
There was particular concern about the problems in reaching those individuals who were pre-verbal or who were not receptive to communicative overtures and who remained isolated. Others appeared to have a motive to communicate but a lack of awareness of how to achieve contact.
Hewett reports how, to begin with, there was much effort to involve the students in the various activities or to help them to make use of simple and relevant signs by which to indicate what they wanted, and generally to develop greater self care and independence.
It was noted that such attempts were commonly unsuccessful or even led to overt conflict.
In the school where Hewett became headteacher, the students were described as all being capable of very challenging behaviour, and most as difficult to reach.
The curriculum at that time emphasised behavioural principles with the teacher taking the lead in selecting and controlling activities, and it was recognised that there was a frequent lack of success in helping individuals to learn particular skills or concepts … with negative implications for staff confidence.
Ongoing discussions and experimentation suggested that the greatest teaching resource was the staff themselves, and, further drawing upon the ideas of Ephraim (eg 1986), there was a gradual shift away from providing activities for the students to join and towards the teacher’s joining the student’s activities.
In other words, the staff sought to enter the students’ world rather than exhorting the students to enter the world set up by the staff.
The adult responded to what the student was already doing, following the learner’s lead rather than adopting the traditional teacher role and trying to take over the lead, and repeating what the learner did as the first step towards becoming accepted in his or her world.
Hewett notes the speed at which infants learn and the breadth of material learned in their first year or so, despite the relative complexity. This is particularly true in the case of communicative skills in that the infant can rapidly develop competence at sharing attention and at participating in increasingly complicated activities, while maintaining eye contact and using/interpreting expressions, turn-taking appropriately, and using more and more verbal as well as non-verbal language.
All this is achieved with parents as teachers, albeit not in terms of their providing a series of tasks and expecting the child to participate. It is a matter of the parental enthusiasm for joining the activities already being followed by the child, ready to select particular aspects of the child’s behaviour and to make some response such as a comment or an elaboration of what the child is doing.
The child recognises that it is his or her actions which are sparking off some reaction in the parent, leading to a greater tendency towards experimenting with “social cause and effect”
These sequences gradually lengthen and grow in complexity to the point where communication exchanges are relatively sophisticated.
The parental style remains interactive and not directive with the infant allowed to maintain the sensation of leading and controlling the activities, including being allowed to determine when (s)he has had enough.
The critical point about the evolving interactive approach in the school was that the adults were creating pleasurable and successful communications by making themselves interesting and by joining the students in their world, their activities, and their behavioural style.
Further introductory thoughts are provided by Nind (2001) who describes how Intensive Interaction was developed during the 1980’s as a means of reaching and teaching students at the earliest stages of communication and social development. The target group was, primarily, the very challenging individuals with severe and complex learning difficulties and those with autism.
This approach, she continues, focuses upon the interaction, at whatever level it has to be, between the communication partners as opposed to working on externally perceived deficits in the individual in question. It is the adult, be it parent, or teacher, or carer, who has the responsibility for adopting an interactive style that is meaningful and fulfils the criteria of ….
These criteria were derived from the interactive style of caregivers who are involved with normally developing infants and the facilitation of shared involvement in activities and of meaningful communication.
Nind describes ongoing evaluation of this approach with reported gains both in the learners’ development and in the teachers’ or carers’ sense of effectiveness and of connectedness with their charges.
The descriptive notes from the British Institute of Learning Disabilities (BILD 2005) also refer to the significant influence of the work of Gary Ephraim and quote his argument that individuals, even adults, with learning disabilities need to learn fundamental communication and social skills in a naturalistic way akin to the kind of interactive relationship between young babies and their parents/carers.
The significance of such an approach is that the skills learned will not be somehow isolated and fail to generalise to different settings or situations, but the individuals will be motivated to continue to use and practise these skills because the experiences are both enjoyable and meaningful.
The goal is gradually to develop a kind of automatic style of interacting with the learning disabled partner in terms of being able to adjust interpersonal behaviours, such as a shift in the tone of voice or intensity of gaze, in order to avoid any threat and to maintain the attention and interest of the learner.
There is a further stressing of the all-important principle of taking the learner’s lead and of responding to what (s)he does, along with commentaries on the actions, sharing them or imitating them, and treating each action taken by the learner as if it is an attempt to communicate so that (s)he will become aware that actions taken can influence events in terms of getting a response (or even a particular response).
The advice is that the Intensive Interaction can be implemented at any time or place, although it appears most effective when the adult is always on the look-out for opportunities as they arise, such as some care task, or a period of quiet activity when the learner appears receptive for sharing an activity.
Further, such opportunities need to occur alongside specifically organised periods in any day when time is set aside for interactive work when there is no other person or responsibility to offer any distraction.
These notes, too, refer to the particular usefulness of the approach when the presenting issue of communication or relating is made more difficult still by additional physical/sensory needs or autism.
It is acknowledged that this kind of approach may seem difficult to reconcile with the goal or principles of normalisation, but it is argued that enhancing the means and motives for communication is entirely legitimate and may provide an opportunity for the beginnings of communication which has not been established by any other strategy.
As evidence, these notes quote Nind’s study (1996) which demonstrated how the participants developed behaviours that were directly influential in making and sustaining interactions, such as looking, smiling, and making vocalisations, and were enabled even to initiate interaction.
There were observed gains in their ability to indicate needs and preferences, to imitate vocalisations, and to interact via sounds and gestures.
In some cases, there was also a reduction of stereotyped behaviours.
In the introduction to their general discussion of Intensive Interaction, Cameron and Bell (2001) quote an estimate from the Scottish Executive Review of Services to the effect that around 50% of people with a learning disability have significant communication problems and up to 80% have at least some problems with communication.
The implication is for a generally poor match between the attempts on the part of staff to communicate and the reported understanding level of the individuals concerned. Reference is made to research findings suggesting that staff are commonly unable to adapt their communication skills or styles to those of the people with learning disabilities.
This becomes all the more important in the light of the evidence reviewed by these present authors that continuing difficulties with communication are associated with low self esteem, anger, self harming behaviour, and social isolation (see, for example Bott et al 1997), with the possible implication that, for many people with learning disabilities, the challenging behaviour has become the only means available of communication, albeit antisocial in its style and potentially counter-productive.
Meanwhile, major problems with speech and language are well documented among individuals with autism.
Communication workshops for care staff and for parents can provide positive opportunities for increasing general awareness of communication issues and offer a number of intervention strategies. However, there is a converging view in the literature that these workshops may have little impact upon the nature of the communication environment with the risk that the gains achieved by these means may be short-lived in the absence of some interactive and feed-back element.
The implication is that Intensive Interaction can offer these elements in providing a setting and set of processes which imitate the mothering process where, for example, there is no particular task to complete but where the aim is to facilitate shared attention and pleasurable and spontaneous play.
Reference is made to Jones (1990) who described the importance of the communication environment as creating “positive spirals of development” … ie when initiation and maintenance of interactions are rewarded through the sharing of experiences which are both meaningful and a source of fun.
The authors conclude by noting the considerable support from evidence-based studies, such as that of Lovell et al (1998) and their own observations of considerable improvements in the cases of a man with severe communication disorder plus seriously challenging behaviour and of a woman very limited communication and significant self-injurious behaviour ….. although it is common among evaluative studies to note reports of initially negative staff attitudes or a lack of long-term commitment to this kind of intervention.
With regard to Intensive Interaction and autism, Nind (1999) recognises how individuals with autism may be perceived by some authors as a very special group in that, for example, personal relatedness with others is a central impairment and that it has a biological basis.
This may be followed by the further view that a lack of connection with others is an area of weakness requiring compensatory interventions rather than something which can be directly remediated.
It also may be held that the intervention has to be special to match the very challenging nature of some autistic symptoms and behaviours (as illustrated by the high demand for the funding of applied behavioural analytic approaches), and that naturalistic approaches have received correspondingly less attention.
However, Nind notes how many of the interactive and non-directive approaches have been associated with significant benefits, and she refers to the Option Approach
(Kaufman 1994) in seeking to engage the child in interaction through responding with a complete acceptance of what he or she does.
It remains the case, nevertheless, that interventions based on naturalistic approaches, seeking to mirror infant-carer interactions, were not seen as dominant at the time of writing (and that probably is still the case now) given the prevalence of the view that individuals with autism need direct training and the use of behavioural principles.
Nind’s own description of Intensive Interaction emphasises how the primary concern is not some particular instrumental response but the quality and enjoyment of the interaction per se. A repertoire of mutually enjoyable games and playful ritualised routines is built up and gradually develops sophistication and reciprocity, emphasising all the while the lead of the learner in selecting activities.
The play and routines provide a safe and stimulating context in which the learner can recognise and experiment with (the effects of) particular behaviours …. as is the case with the reactions that infants elicit from their caregivers; and the minimal and simplified verbal commentary may be likened to the “motherese” adopted by those caregivers to support language use and development.
Nind describes a single case study involving a man in his late 20s who had been diagnosed with autism at the age of 4 years. He presented as withdrawn and aloof, showing no interest in other people and tending simply to push them out of his way.
Over the 12-month implementation of Intensive Interaction, developments were measured using systematic observations with the indication that new behaviours were established such as moving closer to the teacher, turning towards her, looking at her face, and vocalising and smiling.
Joint attention increased, and a greater, apparently interested, watching of other people; more differentiation between familiar people and strangers; fewer signs of distress at the presence or sounds of other people; and a more relaxed state when approached.
A study was completed with special schools in Oxfordshire, involving a questionnaire quest for examples of good practice in Intensive Interaction, and where around half of the responding schools (N = 58) included provision for children with autism.
Benefits reported for the children included ….
Benefits for the staff included ….
There was also the commonly expressed view that the Intensive Interaction approach was very versatile in being applicable almost anywhere and without requiring any special equipment.
One notes also Nind’s point that, in the field as opposed to academe, there was not any “hang-up” or theoretical anxieties about using this kind of naturalistic and interactive approach with children diagnosed with autism. The use of Intensive Interaction as a further intervention was determined on the basis of the needs of a given pupil and the perceived access to the curriculum irrespective of whether the prime need was autism or severe learning difficulty.
Some reservations were expressed, such as a worry about the level of intrusion upon pupils apparently motivated by a desire to defend their personal space, or an uncertainty over the expectation that pupils with autism should enjoy interactions with people.
Nevertheless, Nind concluded that, while interactive approaches may still not attract a high level of direct attention, they are increasingly used and appreciated in the field of autistic spectrum disorders and that such approaches would usefully be made available for children whose learning disabilities are related to, or compounded by, autism.
A further single-case study is described by Kellet (2005) where the child concerned was an 11year old girl with profound learning and communication difficulties, multiple impairments including quadriplegia and seizures, and limited life expectancy.
She was chosen to participate as one of a small group in a study of Intensive Interaction given the view that any development in social interaction, however small, would improve the quality of her life, albeit with some limitations in the data gathered given her frequent illness and her involvement continuing for only 2 terms.
Before the intervention began, Catherine spent most of her time in a passive state, eyes closed or in a fixed stare.
However, during the intervention phase, the extent of “no interactive behaviour” fell from a mean of 82% of the time at baseline to a mean of 56%. Further, as this passive state began to diminish, other socially interactive behaviours were noted, such as greater looking towards the carer’s face and enhanced attention to a joint focus or activity.
Catherine’s mother also reported gains in terms of an increase in the extent of simple interactive games made possible by this approach, such as bubble blowing, and the rewards she gained in the form of smiles and eye contact from Catherine.
After Catherine’s death, her mother described her gratitude that her daughter had been given the opportunity to participate in the study and the delight of the family in being able to make greater connection with her … with those last few months of her life being the happiest time together.
Kellett concluded by describing the experiences gained as adding to the pool of knowledge and understanding of communication development for individuals who are frail and experiencing a range of severe disabilities. Increased hope is afforded for the future with Intensive Interaction providing a tangible scheme for intervention.
The research review by Jordan et al (1998) includes a reference to Intensive Interaction as described by Nind and Hewett, and they note that the practice of imitating and building upon the child’s actions may be followed by increased efforts to alter or extend the child’s repertoire of behaviours …. but with the proviso that any signs of stress or distress will be met by a retreat by the adult into established and familiar patterns of interaction.
Their summary of existing evaluative data can only report that the extent of empirical evidence with respect to autism is small and largely limited to single case or small sample studies; but the implication is that the principles underlying such intervention can be supported by research evidence.
Reference is made to some specific studies which have indicated that the quantity and quality of social responsiveness in children is greater when strategies similar to following the child’s lead are adopted and that social engagement is greater when adult play behaviours closely followed, and were contingent, upon the child’s actions.
Their conclusion is that there is a logical rationale behind these approaches, but that a sole focus upon Intensive Interaction would not be very effective.
Rather, the value of this intervention would be in its inclusion within a well-structured total curriculum which would also cover work on cognitive development, particularly in the area of symbolic functioning, and enhanced communication using gestures and signs and words.
Meanwhile, it might be argued that a primary focus of intervention should be to ensure that an individual with learning disability (or autism) has the maximal opportunity to communicate and that all communication initiatives and responses to communicative efforts should be positive experiences.
With this in mind, one can cite some studies (such as that of Burford 1988) that Intensive Interaction approaches have the potential to support this focus …. and that musical interaction therapy is one further and specific form of interactive and therapeutic play which can enhance communication in children who are unable to benefit from more traditional approaches to encourage some form of social exchange and communication (see, for example, Wimpory and Nash 1999).
Alongside these generally positive thoughts about Intensive Interaction, Culham (2004) refers to a number of concerns expressed by male professionals about their involvement in this kind of intervention. In particular, there is concern about the issues of closeness with female clients and the possible misinterpretation or misrepresentation of their interactions with these learners.
Culham recognises the considerable diversity in communicative style and practices within and between gender groups, but notes that some general male or female “styles” are sufficiently common to reflect distinctive gender-differentiated patterns.
For example, women lean towards an emphasis upon people, feelings, and relationships; men lean towards specific tasks and some instrumental outcome. The male style is more competitive and female style more collaborative.
It appears also commonly to be the case that young infants interact more with their mothers than with their fathers during the pre-school years, but may shift in their communication priorities towards the fathers from the age of 4+ or 5 onwards.
The question is raised whether male practitioners of Intensive Interaction are, or are perceived to be, somehow experientially and psychologically different from other men who work in different fields.
On the other hand, there is concern at the growing scarcity of male workers within teaching or support services and in the caring professions with negative implications for the delivery of the curriculum in areas like PSHE, role modelling, behaviour management, and team working (with particular regard to boys or young men as learners and clients).
A survey carried out by Culham among male practitioners involved in Intensive Interaction confirmed how this approach is seen as a valuable means by which to enable people with learning disabilities to engage with others …. to express their needs or wants, likes and dislikes, or simply to initiate a relationship with another person.
There is, in other words, a clear interest in, and support for, this approach but the respondents consistently highlighted their need for further support and development in their work. To begin with, there was a perceived need to attract more men into work of an intensive interactive kind, and to determine how this kind of nurturing work can be maintained in the face of gender-differentiated expectations from the wider society.
Culham’s conclusions and implications include a reinforcement of the need to recruit more male practitioners to provide a greater balance for the learning-disabled clients, and a challenging of the questioning or negative attitudes that may be directed towards men already working via wider dissemination of the theory and practice through increased training courses.
Meanwhile, policy documents and guidelines concerned with physical proximity and age-appropriateness of interventions are required to help protect both the learners and the practitioners. Such written materials should be backed up by a support structure to provide ongoing advice, mentoring, and support.
In sum, both managers or fellow professionals, as well as the public at large, would benefit from a greater understanding of Intensive Interaction, its procedures, and the associated implications.
* * * * * *
Bott C., Farmer R., and Rohde J. 1997 Behaviour problems associated with lack of speech in people with learning disabilities. Journal of Intellectual Disability Research 41(1) 3-7
Burford B. 1988 Action cycles. European Journal of Special Needs Education 3(4) 189-206
Cameron L. and Bell D. 2001 Enhanced interaction training. Learning Disability 18(3) 1-7
Culham A. 2004 Getting in touch with our feminine sides ? Men’s difficulties and concerns with doing Intensive Interaction. British Journal of Special Education 31(2) 81-88
Ephraim G. 1986 A Brief Introduction to Augmented Mothering. Radlett, Herts : Harperbury Hospital
Hewett D. 2005 About Intensive Interaction. www.davehewett.com/intensive.
Jones S. Intecom. Windsor : NFER-Nelson
Jordan R., Jones G., and Murray D. 1998 Educational Interventions for Children with Autism. Research Report 77 Norwich : HMSO
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Kellett M. 2005 Catherine’s legacy : social communication development for individuals with profound learning difficulties and fragile life expectancies. British Journal of Special Education 32(3) 116-121
Lovell D., Jones S., and Ephraim G. 1998 The effect of intensive interaction on the sociability of a man with severe intellectual disabilities. International Journal of Practical Approaches to Disability 22(2/3) 3-9
Nind M. 1996 Efficacy of intensive interaction. European Journal of Special Needs Education 11(1) 48-66
Nind M. 1999 Intensive Interaction and autism : a useful approach ? British Journal of Special Education 26(2) 96-102
Nind M. 2001 Intensive Interaction. In Approaches to Autism, London : National Autistic Society
Nind M. and Hewett D. 1994 Access to Communication. London : Fulton
Wimpory D. and Nash S. 1999 Musical Interaction Therapy. Child Language Teaching and Therapy 15(1) 17-28
© Mike Connor 2005.
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