Thursday, 14 November 2019

Using Intensive Interaction with learners or service users who present with some level of ‘engagement and/or task avoidance’

My Blog this week is admittedly quite long - but please stick with it as I think it addresses a vitally important but little discussed issue. Here goes:

The 2019 Intensive Interaction Weekend Workshop discussed using Intensive Interaction with learners or service users who presented with some level of engagement or task avoidance*. We collectively as participants thought that we saw a range of children or adults who fitted somewhere along ‘a broad spectrum of engagement or task avoidance’ with such generalised ‘avoidance’ often differing in its form and severity 

(*We purposively did not base our discussions on considerations of the apparent or claimed symptomology or diagnostic processes (or even legitimacy) of the condition known as Pathological Demand Avoidance (PDA), as we felt this would channel and constrain our thinking away from considerations of some of our own learners or service users, who we all felt did fit somewhere along ‘a broad spectrum of engagement or task avoidance’).

We asked ourselves the following questions: 

1. How might any such ‘engagement and/or task avoidance’ be presented?

2. Why might any such ‘engagement and/or task avoidance’ occur?

3. What factors might perpetuate someone’s ‘engagement and/or task avoidance’?

4. How might Intensive Interaction help ameliorate the impact of ‘engagement and/or task avoidance’ for such learners or service users?

The results collated from all the participants in the workshop activity:

1. How might a person’s engagement or task avoidance be presented?
  • Having a ‘Melt-down’ e.g. shouting, crying, throwing things, jumping on tables, causing environmental damage, etc.
  • Engaging in self-injurious behaviour e.g. hand biting, head slapping, etc.
  • Becoming violent e.g. punching, kicking, etc.
  • Engaging in inappropriate social behaviour e.g. swearing, abusing others, laughing (at unfunny things), grounding, masturbation, stripping, etc.
  • Verbally declining (“no thanks”) or refusing (“No!”) tasks that the person has the ability to do, or has even historically liked doing.
  • Ignoring or not responding to requests or the presentation of an activity.
  • Closing down a conversation e.g. “its okay luv”, “Not just now” or giving apologies before not doing something.
  • Steering a conversation or creating a distraction away from, any given demand.
  • Hiding offers of activities e.g. destroying letters, leaflets or invites etc.
  • Physically pushing things or people away, out of their immediate space.
  • Physical isolation e.g. staying in bed, staying in room, not going out, etc.
  • Physical withdrawal e.g. leaving the room, turning their back, etc.
  • Social withdrawal i.e. retreating to an ‘inner world’ e.g. shutting eyes, avoiding eye contact, self-soothing.
  • Regulating aural and/or visual input e.g. looking away, putting fingers in ears, etc.
  • Incongruent verbal and/or non-verbal behaviour i.e. saying something verbally but doing the opposite behaviourally.
  • Switching sleep patterns to avoid engagement or contact with others e.g. sleeping during the day, being up at night.
  • Using prolonged engagement with technology (or other rigidly focused object orientations or activities) as a shield from external demands.
  • Using rigid routines to control the level of potential demand in any given situation.
  • Responding negatively to everyday requests (not just potentially novel or potentially ‘challenging’ things); even failing to choose between some offered positive choices.
  • Responding negatively to positive comments or praise from others.

2. Why might someone be (or become) engagement or task avoidant?
  • Chronic anxiety, including social anxiety and/or prolonged exposure to stress.

  • A fear of the unknown, and a wish to avoid uncertainty; a fear of failure, of getting something wrong; a fear of being judged by, or of disappointing others.
  • Needing to control a situation (possibly in response to some change or as a means of protection from something) and/or being unwilling to be controlled by others.
  • A lack of understanding about what is being asked, leading to anxiety about their ability to complete the given demand.
  • Previous or continuing negative experiences leading to trauma.
  • A historic lack of positive interactions or feedback in any previous engagements.
  • Low confidence or self-esteem and/or a negative self-view or self-worth.
  • A lack of the necessary social skills to engage with others.
  • A ‘power’ issue, seeking power over those around who historically or currently hold power over the person.
  • Due to the onset of puberty and the resultant changes in hormonal levels and/or the menstrual cycle.
  • Being in pain or having other medical or health related issues e.g. musculoskeletal, of the bowels, etc.
  • Being in a constant state of exhaustion through maintaining a physical posture.
  • Being on psychoactive or other medication (e.g. tranquillisers, anti-epileptics), thus reducing cognitive functioning.
  • The result of some form of sensory processing disorder or other sensory issue.
  • Not being cognitively, emotionally or physiologically ‘ready’ in some way.
  • As a means of gaining and holding prolonged attention (even if that is negative attention) from others.
  • Boredom with or not being interested in the potential ‘demand’ i.e. not being genuinely demand avoidant.
  • Neurodevelopmental issues (incl. P.D.A. diagnosis).

3. What other factors might perpetuate someone’s engagement and/or task avoidance?
  • The demands being made are too often too complex or unfamiliar or unpleasant or uninteresting.
  • A continued lack of trust in others e.g. due to previous ‘false promises’ e.g. “it’s gonna be okay”.
  • A confusing lack of consistency experienced across previous engagements with others.
  • Continued experiences of simply not being listened to by others.
  • A physical or cognitive deterioration in the person.
  • Too much language used, too little processing time.
  • Both the person and their carers getting stuck in a negative cycle of perceived and expected failure.
  • There being a hierarchical power issue i.e. a battle for control between the person and their carers/staff.
  • The use of over-enthusiastic and/or non-genuine initiations or invitations to join in with an engagement.
  • Some response from third party reinforcing the behaviour.
  • Not addressing a need to alter a current sensory environment.

4. Strategies used within an Intensive Interaction intervention to ameliorate the impact of a person’s engagement or task avoidant avoidance:
  • Pausing a lot, and for longer; allowing the person extra processing time.
  • Being indirect with requests or invitations e.g. “Bet I can get my coat on before you” will be better than “put your coat on” … or “I’m going now”.
  • Being careful when using language e.g. at times more, at times less; using comments and/or statements instead of questions or requests e.g. “you can join me if you want” or “I don’t know where this goes”.
  • Sometimes providing reassurance e.g. “we’re all ok”.
  • Consider reducing the volume of vocalisations: try whispering!
  • Providing ‘failure free’ (i.e. unstructured) tasks or activities, led by the person.
  • By staff initiating an activity and allowing the person to just observe, before they then choose to join in (if they want to).
  • Reducing the availability of eye contact, if this adds to a perceived level of demand.
  • Creating some kind of ‘joint activity’ out of less obvious ‘joint activity’ situations when led by the person.
  • Do things alongside or in parallel, but actually not with the person (and sometimes at a distance).
  • Presenting the person with ‘Unconditional Positive Regard’ (UPR) irrespective of any level of engagement.
  • Being taskless; just seeking ways of equitably ‘being with’ the person.
  • Making any necessary adjustments to the sensory or social environment (possibly to tone it down?).
  • Being thoughtful about too much, or too little proximity i.e. not being too far away/too close in.
  • Being open-minded and genuine, whilst persevering and demonstrating empathy.
  • Looking to match the mood and presentation of the person in the current situation… let the person lead.
  • Knowing when to stop (i.e. when they’ve had enough), whilst also trying to wind down when things are still going well i.e. ending on a positive.
  • When stuck seeking help and/or peer support e.g. by using video analysis for constructive feedback and new ideas.
  • Re-labelling ‘avoidance’ to something like ‘engagement and/or task avoidance’ (as in this document) so that we do not get confused with the approaches used with those whose avoidance is diagnosed as ‘Pathological’.
Finally, some potential outcomes of the use of Intensive Interaction with people with engagement and/or task avoidance:
  • Improved social engagement with staff or carers.
  • Improved relationship development.
  • Improved psychological well-being e.g. in mood and self-esteem.
  • Improved staff rapport and morale.
  • Improved emotional well-being.
  • Improved access to educationally enabling activities and engagements, increasing the potential for all future educational and social outcomes.
  • Greater independence for the individual.
  • A generally improved quality of life!

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