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 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 Correspondence
[email protected] 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 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
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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. 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? 16 December 2013 | Volume 16 | Number 10
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
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). LEARNING DISABILITY PRACTICE
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 17
Art & science | communication Figure 1 Responses to questions 1-4 and 10 14 13 12 -
Yes No Other
Number of respondents
11 10 9876543210-
Question 1
Question 2
Question 3 Answers to questions
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
Question 4
Question 10
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 87-
Number of respondents
65-
Yes, a lot Yes, quite a lot Yes, somewhat Yes, a little No Other
43210-
Question 5
Question 6
Question 7
Question 8
Question 9
Answers to questions
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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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Conflict of interest None declared
References Anderson C (2006) Early communication 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 of a child with autism in a Greek preschool inclusive class through intensive interaction: a case study. European Journal of Special Needs Education. 27, 1, 99-114. Barber M (2008) Using intensive interaction to add to the palette of interactive possibilities in teacher-pupil communication. European Journal of Special Needs Education. 23, 4, 393-402. Buchanan D, Claydon T, Doyle M (1999) Organisation development and change: the legacy of the nineties. Human Resource Management Journal. 9, 2, 20-37. Cameron L, Bell D (2001) Enhanced interaction training: a method of multi-disciplinary staff training in intensive interaction to reduce challenging behaviour in adults who have learning disabilities and who also have a severe communication disorder. Working With People Who Have a Learning Disability. 18, 3, 8-15. 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.
Firth G, Elford H, Leeming C et al (2008) Intensive interaction as a novel approach in social care: care staff’s views on the practice change process. Journal of Applied Research in Intellectual Disabilities. 21, 1, 58-69. 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. Kellett M (2003) Jacob’s journey: developing sociability and communication in a young boy with severe and complex learning difficulties using the intensive interaction teaching approach. Journal of Research in Special Educational Needs. 3, 1, 18-34. Kellett M (2004) Intensive interaction in the inclusive classroom: using interactive pedagogy to connect with students who are hardest to reach. International Journal of Research and Method in Education. 27, 2, 175-188. 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, 116-122.
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Kennedy A (2001) Intensive interaction. Learning Disability Practice. 4, 3, 14-15.
profound intellectual disabilities. Journal of Intellectual Disabilities. 12, 2, 111-126.
Leaning B, Watson T (2006) From the inside looking out: an intensive interaction group for people with profound and multiple learning disabilities. British Journal of Learning Disabilities. 34, 2, 103-109.
Sharma V, Firth G (2012) Effective engagement through intensive interaction. Learning Disability Practice. 15, 9, 20-23.
Lovell D, Jones S, 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: developing sociability and communication in people with severe and complex learning difficulties using an approach based on caregiver-infant interaction. European Journal of Special Needs Education. 11, 1, 48-66. Nind M, Hewett D (2001) A Practical Guide to Intensive Interaction. BILD, Kidderminster. NHS Modernisation Agency (2003) No Going Back: A Review of the Literature on Sustaining Strategic Change. NHS Modernisation Agency, London. Samuel J, Nind M, Volans A et al (2008) An evaluation of intensive interaction in community living settings for adults with
Watson J, Fisher A (1997) Evaluating the effectiveness of intensive interactive teaching with pupils with profound and complex learning difficulties. British Journal of Special Education. 24, 2, 80-87. Watson J, Knight C (1991) An evaluation of intensive interaction teaching with pupils with severe learning difficulties. Child Language Teaching and Therapy. 7, 3, 10-25. Zeedyk S, Caldwell P, Davies C (2009A) How rapidly does intensive interaction promote social engagement for adults with profound learning disabilities and communicative impairments? European Journal of Special Needs Education. 24, 2, 119-137. Zeedyk S, Davies C, Parry S et al (2009B) Fostering social engagement in Romanian children with communicative impairments: the experiences of newly trained practitioners of intensive interaction. British Journal of Learning Disabilities. 37, 3, 186-196.
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