Some Intensive Interaction 'recording’ issues to think about

Following on from last week's blog which set out my position on the human bias which can 'unconsciously and unquestioningly project too much confidence into a set of sometimes quite crude numbers' (14/05/18), in this blog I thought I might set out what I think is generally important when considering which recording regime (or formats) might most usefully collect information/data on the use of Intensive Interaction.

When considering a recording regime (e.g. a combination of recording formats) to be used during an Intensive Interaction intervention (or just during its general use), I think there isn't a simple 'one size fits all' system. Instead I think that there are various stages of an Intensive Interaction intervention (or its general use) that might require the use of different recording formats.

At the start of an Intensive Interaction intervention a systematic collection of information might be required about what a person does: in what way(s) they behave, what kinds of actual or potentially sociable activity seem to positively motivate them, and in what way(s) they might be socially communicative (either currently or potentially).

As an intervention progresses, the systematic collection of both objective and subjective information might then be required on how sessions are developing, which kinds of interactivity are working well, and which aren’t. Some types of recording might be used to evidence the levels of engagement attained by the person with whom we are interacting, and others formats used to support a reflective analysis on a practitioner’s individual practice. It might also be useful to systematically record any new ‘interactive’ developments that the person evidences.

Additionally, when thinking about which recording formats to use, and when, the following issues might be usefully considered:

     ·   the purposes and potential audiences for any information or data collected should be made clear to those people who are doing the recording. 

     ·   any recording format should be both broadly applicable and efficient i..e. quick, clear and flexible enough to record an interactive episode, or at least some important aspect of an interactive episode, of any participant engaging in Intensive Interaction.

      ·   any recording regime should be able to show a person’s development or progress over time, even if such progress is only incremental and/or inconsistent i.e. it should help build a picture of the person’s interactions over an extended period of time, rather than just giving a one-off and potentially misleading snapshot.

      ·  any recording regime should be able to evidence any new or novel interactive occurrences.

Another (perhaps ulterior) consideration for using a systematic recording regime is that it can provide good evidence of the quality (and quantity) of Intensive Interaction service provision, and thus clearly indicate compliance with a number of specific CQC or Ofsted outcomes (and thus help gain that all important 'Outstanding' rating).

Finally, any recording regime should also ideally include regular video recording, to provide comprehensive and easily accessible evidence of Intensive Interaction attainment and progression, and also help individual practitioners and services use and record Intensive Interaction in the most effective and most consistent ways possible.  

The human bias to numbers? Do we unconsciously make the numbers fit the activity, or the activity fit the numbers?

A recent works e-mail that I had forwarded to me has given me some real (actually metaphorical) food for thought about the credence we perhaps unintentionally give to things that are represented as numbers, or in numbers. There is something about their exact and (apparently) clear nature that seems to imbue numbers with a some sort of robust certainty ... a clarity and concreteness that we all tend to project into or onto them, and their use. 

This is where my thoughts were stirred from their usual slumber (this is sadly degenerating into a series of very mixed metaphors) as the email I received contained numbers representing the clinical ‘Contact Activity' of me and my fellow staff working across our CLDTs. What struck me was the wild variation in this represented ‘activity’, with my count being disappointingly low (I had always suspected that I was either lazy, incompetent, or both; and now I and many of my colleagues have the hard edged quantitative numbers to prove it!). 

But the nub of my thoughts were this: 

Do these numbers reflect something that is actually really real i.e. real in the sense of reflecting something that actually exists in the real/concrete world (the one in which we all live, and not just the subjective world we all inhabit in our own minds) - well yes, to some degree, obviously! 

…but then I asked myself exactly what do these numbers represent or reflect? As with many quantitative recordings or measures ... can we be exactly sure what each of these numbers represent? So I then asked myself these questions: 

a. is exactly the same thing being recorded (e.g. ‘Contact Activity') by multiple recorders in each and every instance i.e. are all the recordings of precisely the same thing? ... and also, 

b. are all the instances of this precise same thing actually recorded? ... and then I asked,

c. are the recordings of these apparently exact same things being interpreted in exactly same way by the outside observers when they read these numbers and individually create their own meaning from them (i.e. that I am lazy and/or incompetent)? ... and then (stick with it, there's a chance it might be interesting), 

d. is this interpretation the same as all the multiple recorders thought the numbers meant? i.e. is what is coming out with these numbers exactly the same as what went in with these numbers? and finally: if so, or if not, how would we know? 

So my question is generally about our superficial acceptance of numbers in many aspects of work and life and what they purport to represent (which to me seems to have all the hallmarks of fitting within some sort of unconscious cognitive bias). I suppose all I am saying is that I think that sometimes numbers can sneak in some unwarranted confidence in their own actuality and meaningfulness (when shared in certain decontextualised ways).

Not that I am against numbers in many fields – they are utterly invaluable when used and reported correctly (as with many robust quantitative research studies - although please remember here that some studies tend to be somewhat reductionist in nature when they end up representing complex issues as just numbers! - they can never tell the whole story).

So, we should always be wary that we might consciously or unconsciously fall prey to our internal bias and unconsciously and unquestioningly project too much confidence into a set of sometimes quite crude numbers - they can at times confuse a picture ... by at best being quite meaningless, but at worst they might actually be misleading (I hope!).

We all have something in common: we all share the aim of enabling positive and affirming human social contact for all the people who need it.

Last week I was lucky enough to be a part of two different Intensive Interaction events - firstly doing some teaching on organisational change on the Intensive Interaction Institute Coordinators course in Great Malvern, and then sharing a weekend in Malham with 22 other Intensive Interaction practitioners focusing on using Intensive Interaction with people with language.

I suppose what I took from these two very different events was how we … and across these two events 'we' were a mixture of teachers, teaching assistants, speech & language therapists, a speech and language technician, an occupational therapist, adult residential staff, adult sessional support staff, a parent, senior leaders, a researcher, a learning disability nurse, an II coordinator/practitioner, and me ... with varying levels of professional qualification and/or none … how we all share a common belief in and passion for creating positive and affirming human social contact for people (adults and children, and now also older adults with dementia) who had a communication or social impairment – whether that be when looking for educational, social or therapeutic outcomes.

But I also took something else; a realisation that Intensive Interaction has certain fundamental qualities about it that mean that, as a social communication approach, it is open for us all to do, at least to some degree, from the most novice practitioners to gnarled old timers like myself.

And I also started to think about some of the things that set Intensive Interaction apart from other approaches used within our respective fields, these being that:

• Intensive Interaction doesn't need a particular qualification for practitioners to start to do it – as can be seen by the range of people on these two events - we come to Intensive Interaction from many different working and/or care contexts; in fact the approach embodies some common humanistic values that we all seem to share - although obviously good quality training and/or supportive mentoring in the rationale and practices of Intensive Interaction is essential for positive practice development. 

• Intensive Interaction doesn't need complex and esoteric (and sometimes methodologically opaque) professional assessments of certain areas of skill (or deficit) or performance (or behaviour) to identify those who should be a recipient of our socially inclusive Intensive Interaction - although obviously the involvement of consulting professionals can always strengthen a case being made for the sustained provision of the approach. 

• Intensive Interaction doesn't need professional gate-keepers i.e. those who might assume authority to say who can and who can't at least try to do Intensive Interaction at some level, to the best of their ability, given that we are all on a journey of our own practice development - although obviously having champions for Intensive Interaction who work to identify and nurture fellow enthusiasts and supporters can be very useful. 

• Intensive Interaction doesn't need the person who receives it to have been given an official and/or professional diagnosis of any particular condition, disorder or syndrome - although having a diagnosis of certain developmental conditions or intellectual disabilities that affect communication and/or sociability will obviously make a case stronger for its provision.

But also I took from my interactions with all the people over this last week a renewed feel for the real power of peer support within an identifiable community of practice, of the positive benefits of inclusively sharing our Intensive Interaction experiences and viewpoints, and of the great value of receiving (and giving) encouraging and constructive feedback to support individual and collective reflection on our Intensive Interaction practices.

Phew - what a week!

So many thanks to Elizabeth, Lena, Gillian, Emily, Eleanor, Tom, Julie, Wendy (twice - that's just being greedy!), the three Jos, Stella, Jayne and Catherine, Anne and Nancy (apparently Victoria is waiting to hear all about it), Nick, Lynnette, Janet and Anne, Charlotte, Sharon (all the way from Cornwall!), Paula, Liz (don’t forget the research summary!) and Rachel, Neal and Frances (great curry!), Claire and Sam – all your contributions to our dynamic, open and expanding Intensive Interaction community of practice were all very welcome.

Education, Health and Care Plans & Intense Interaction

Recently Dave Hewett posted in the 'Intensive Interaction Users' Facebook page, and he shared a question he had been asked by a mother of a child with autism about whether anybody had experience of getting Intensive Interaction stipulated within an Education, Health and Care Plan (such an Education, Health and Care (EHC) plan being a UK statutory educational plan for children and young people (aged up to 25) who need more support than is available through generic special educational needs support). 

Such EHC plans identify a child's educational, health and social needs, and set out the additional support required to most effectively meet those stipulated needs. Anyway, Dave then asked members of our 'Intensive Interaction users' whether anybody could share any advice on successfully getting Intensive Interaction stipulated within an EHC plan. Below I try to bring these responses into a hopefully helpful single Blog piece:

KW: My team recommend II regularly in child and adult services and is contained in paperwork. EHCPs will also contain II where it has been recommended by the therapist ... with an additional comment of: JV: Yes, we had it agreed by our therapist.

MB: We have it recommended in our twins EHCPs ... we have sessions to be delivered by SLT to our children with their TAs ... and then for the TAs to use II with the boys both generally in their interactions and in some discreet sessions during the week.

KM: I have typed up a form that captures and rates the adult's competency using PAVE (taken from an idea from Phoebe Caldwell).

SC: No reason why it can't be included under the 'Communication and Interaction's part. Fits in perfectly ... with an additional comment of: EF: Also perfect for the ‘social, emotional and mental heath needs’ section.

BE: In ours we have it in the pen portrait, what is needed for them and in the provision and sometimes in the targets! It has never been queried.

JS: We attend the joint assessment meetings where possible to co-write the EHCP, if Intensive Interaction is needed we put it in ...

GPP: For us it would be in the provision and especially in the Pupil Passport which contains short term targets towards the long-term outcomes. We have a list of provision which is ticked if children access it and II is one of these You may find that the outcomes and provision on the actual plan are quite vague.

DT: Have referred to II in Leeds in care plans for young people and adults as a guide for communicational style and emotional engagement. Not putting in place pure II sessions as an educational strategy necessarily but still helpful because it gives a clear context for lots of things we might do or do less or leave undone.

AH: We always add Intensive Interaction either in the social skills or communication skills section. Normally set it within an outcome or within the how outcomes will be achieved section ... with an additional comment of: DL: We do the same as this at our college.

LM: I’ve stipulated it in a recent EHCP I have amended for a young lady I teach. I’ve written it in the communication part and where the detail of how to support her best is.

HP: Make sure I.I. is written into the 'Provision' as this is then legally binding.

JL: I'd say it's in the majority of plans in a range of sections through the plan. It's crucial it's in the provision section in how to achieve outcomes as some LA's will only fund what's named in the outcomes and provisions (section F).

KM:Yes in many plans I have contributed to. We make sure by including an outcome that is dependent on its use. The framework that describes levels from Encounter through to Student Initiates helps a lot ... with an additional comment of: EBC: Yes, in the provision part,section F.

PJR: We have EHCP targets like: ‘... will engage in intensive interaction activities for up to 10 minutes, at least 5 times a day.’ Obviously the length of time and regularity change depending on the needs of the child. But all the pre verbal children in my department have something similar to that.

So the answer seems to be a resounding 'Yes'. You can, and you should get Intensive Interaction into a EHCP, with the more specific advice being: 

• Be the person that is active in writing up the EHC plan with a mind to including Intensive Interaction. Also, try to get it recommended by a Speech & Language Therapist. 

• You can include Intensive Interaction under the 'Communication and Interaction', 'social, emotional and mental heath needs', 'social skills' or 'communication skills' sections of the EHCP. 

• You should also include Intensive Interaction as an outcome, or put it in the 'how outcomes will be achieved' section. 

• You should set Intensive Interaction specific targets like: Child A ... ‘will engage in Intensive Interaction activities for up to 10 minutes, at least 5 times a day’. 

• You should make sure that Intensive Interaction is written into the 'Provision' section of the EHCP, as this is then legally binding, and some Local authorities will only fund what's named in the outcomes and provisions (Section F). 

I hope this helps all those faced with a similar prospect; and it is always a good idea to exploit the key drivers of an organisational system to support the delivery of appropriate provision for individuals within that system - and sharing an understanding of how it has worked in the past can only be a real help for others seeking similar positive outcomes.

Therefore many thanks should go to 'II Users' - Catherine, Jane, Michelle, Karen, Suzi, Eva, Becca, Jenny, Gaynor, David, Aileen, Jennie, Debra, Louise, Hayley, Ellen & Paula for your very helpful contributions.

More 'indirect' evidence in support of Intensive Interaction practices?

Continuing the theme from my recent blog (Using 'Perseverative Interests' ... 02/04/18) about 'indirect' evidence supporting aspects of Intensive Interaction practice, I was recently pointed to an interesting case study (by II Institute Associate Jules McKim) that described the use of 'silent mirroring' in the treatment of Ms M., a 75 year old woman with a diagnosis of chronic paranoid schizophrenia, dementia with agitation, and several medical problems. Below I set out some extracts about the case from the paper:

The Mirror of Silence: A Method of Treating a Preverbal Schizophrenic Patient

Susan R. Blumenson (1993) Modern Psychoanalysis, 18(3), 179-189.

‘During her 3 years in the nursing home Ms M. spent her time in bed or in a wheelchair ... she was minimally verbal and unresponsive ... When spoken to or questioned, Ms. M. would turn away without responding ... She was agitated much of the day – constantly shifting from side to side in the wheelchair crossing and uncrossing her legs, turning her head, placing her hand with outstretched fingers over her face covering her mouth, nose and eyes.’

The 3 months of treatment for Ms M. was described  by the clinician as 'basically silent mirroring of her bodily movements', by the end of which ... ‘Ms. M. had stopped being verbally disruptive and her physical agitation had diminished to a fraction of its original form. She had accepted the presence of the analyst as she sat with her, she had stopped screaming except for rare instances, and she had responded verbally several times to the analyst’.

At the end of the paper the author concluded that: ‘Whatever had happened in Ms. M.’s life had caused her to retreat behind a defense of not talking. Her screams were understood to be a form of communication, presumably of discomfort or displeasure, perhaps a plea for attention. Being minimally verbal seemed to be her attempt at withdrawing from a hostile environment while maintaining a slim thread of verbal contact, at her discretion. She rejected the world as it undoubtedly had rejected her’.

Now, as I said in my last but one post, 'silent mirroring' is not in itself Intensive Interaction, but it is (or was) a therapeutic approach that clearly utilises one of the main practices of Intensive Interaction (behavioural mirroring); it clearly resulted in reduced disruption and agitation, 'to a fraction of its original form', as well as an increase in Ms. M's verbal responsiveness. 

So again I ask,  does this case-study add to the evidence base for Intensive Interaction [which, as noted above incorporates forms of 'mirroring' as one of its central features] ... well, again I would say "yes"; again only indirectly, and again only for this one particular 'mirroring' strategy ... but I think it is still a 'yes'.

Interestingly, in her exploration of 'the literature' that informed her therapeutic intervention the author points us to other evidence that I think indirectly supports aspects of Intensive interaction practice: 

'Spotnitz (1985) … discusses “joining techniques” … especially those reflecting preverbal functioning. The therapist makes interventions which support and even reinforce continuation of the resistance until such time as the patient develops awareness and ego strength to replace it with more adaptive and controlled behaviour'.

'Tiegerman and Primavera (1981) conducted a study of object (toy) manipulation with autistic children. The behaviour characteristics of the children included: mutism or echolalia, looking at or through people, an indifference to physical contact, rocking and head-banging, among others. The experimenters discovered that imitation of the child’s performance by the experimenter was most effective in increasing the frequency and duration of object manipulation in the autistic subjects.  Their data support the premises that the imitation of the child by the adult may be a critical factor in the autistic child’s learning to establish and maintain interaction. Imitation of the child placed her/him in complete control of the environment, the adult and the adult’s performance’.

So, irrespective of age, diagnosis or presentation, there is something going on here that goes to the very heart of how we treat (clinically or generally) other people with communication and/or social impairments. It would appear from a wide range of evidential sources that, if we focus on our common humanity, and treat other people (clinically or generally) in a socially responsive and empathetic manner, we should expect to get better social and therapeutic outcomes! (no s**t Sherlock!)

Care Quality Commission identifies Intensive Interaction as an 'Outstanding' care practice!

The Care Quality Commission (the quasi-governmental body charged with inspecting and regulating the quality of health and social care services here in England) has recently inspected our trust's Specialised Supported Living Service - an NHS managed and staffed residential service here in Leeds for people with severe or profound learning difficulties. In their report findings they stated that:

Is the service effective? Rating = 'Good'!
Since the last inspection, the registered manager had developed champions in areas such as PBS, Makaton, postural management and Intensive Interaction ... A member of staff told us about the training they had received around Intensive Interaction. They said, "I have not only seen our residents benefit from us knowing about this but it has enabled me to be more confident. I feel it has brought me out of my shell. I see that I am part of the communication process and that I need to communicate back to people. This was the best training I have ever done*."  

(*GF- my underlining, not theirs; and there's a box of chocolates waiting in my office for the, as yet unidentified staff member who said that!) 

Is the service caring? Rating = 'Outstanding'!
People and their relatives told us that staff delivered extremely person centred care and support ... Staff had exceptional knowledge about people's preferred communication ... A support manager told us, "To work with the people we work with, with such profound multiple needs, Intensive Interaction is required to build up positive working relationships." The provider had ensured staff had received training in specialised communication such as Intensive Interaction ... The benefits of staff having knowledge and using their skills meant people were able to express themselves, be involved and direct their own care and support.

So congratulations must go to:

a) Gill Galea (Operational manager) and her 'outstandingly' caring staff team for demonstrating 'outstanding' levels of care, evidenced to the CQC inspectors through their (best ever!) training in and use of Intensive Interaction; apparently this being identified on the first day of the inspection by one of the inspectors asking: "So, where will we see Intensive Interaction in action?"

b) The CQC and their team of inspectors for clearly identifying Intensive Interaction as one of the main means through which an effective and outstandingly caring service is enacted (and therefore evidenced) on a day by day basis - which it self-evidently is.

This also reminded me of the work of Debbie Whiting, an Intensive Interaction coordinator working for the Frances Taylor Foundation (and winner of our 2016 'Intensive Interaction Practitioner of the Year'), whose service also received an 'Outstanding' rating from CQC for its care, evidenced via the use of Intensive Interaction. CQC said of their St Joseph's service:

'Everyone we spoke with, without exception, commented on the caring nature of staff. One relative said, "They are an absolute joy." Another said, "They are just amazing." ... All staff had adopted an ethos of 'Intensive Interaction' which shaped the care delivered at the home ... Staff were passionate about this and we saw from our observations that it meant a lot to people. People were smiling and laughing and looked genuinely cheerful and happy. We saw examples of this interaction taking place, and could see what it meant to the people living at the home.'

So perhaps the secret is finally out (I know its not really a secret, I am only saying that for dramatic/literary effect) - if you want to be judged by CQC as  an 'outstanding' residential service for people with severe or profound learning difficulties ... them show them the Intensive Interaction!

Using 'Perseverative Interests' ... as joint focus activities in Intensive Interaction

Perseveration is defined as an uncontrolled, repetitive behavioural response to a set stimulation, despite the termination of the initial stimulation, the continuation of which appears contextually irrelevant to the current situation. The definition of 'perseverative interests' (PI) in the DSM (4th Ed), is: 'encompassing preoccupations with one or more stereotyped and restricted patterns of interest that are abnormal either in intensity or focus'.

Now the reason I am blogging about perseverative interests (or behaviours) is that during Intensive Interaction I will often join-in with such highly repetitive and 'contextually irrelevant' behaviours to try and create a person-centred and joint-focus, social engagement context ... and I recently came across a paper (Vismara & Lyons, 2007) that suggested that if an individual’s perseverative interests are integrated into the topic of a joint focus activity (in this case as part of an approached called Pivotal Response Treatment), then this was found to enhance that individual’s levels of social engagement (no s**t Sherlock!). So here are some interesting (well to me anyway) extracts from the paper:

'Perseverative Interests to Elicit Joint Attention Behaviours in Young Children with Autism' 

Vismara, L. & Lyons, G. (2007) Journal of Positive Behaviour Interventions, 9(4), 214-228. 

This study looked 'to examine whether joint attention initiations for social sharing would occur as a collateral effect of utilizing the motivational techniques of Pivotal Response Treatment (PRT) in conjunction with perseverative interest stimuli for three young nonverbal children with autism' ... using 'a large variety of highly preferred age-appropriate board games, activities, and toys'...  (and people sometimes say that I'm a bit 'too wordy'!) ... anyway: 

'[The] results indicated an immediate increase in joint attention initiations when perseverative, or highly preferred, interests were incorporated within the motivational techniques of PRT. Additional findings included collateral increases in joint attention initiations towards less preferred interests, as well as improvements in the quality of interaction between the children and caregivers' (my underlining not theirs).

'In summary, the findings suggest that using PI stimuli in conjunction with PRT appears to increase a child’s motivation to share his or her perseverative interest socially with another person and consequently to improve the quality of initiations and interactions. In addition, this study indicates that children in this type of intervention use their perseverative interest in a socially appropriate and controlled manner without the presence of negative side effects. The results are also promising in terms of providing an approach that utilises learning mechanisms that may be similar to those used in typical development'. 

Now 'Pivotal Response Treatment' (PRT) is not Intensive Interaction (it is a more behaviourally abstracted, controlled, and less naturalistic approach), but it clearly utilises one of the practices of Intensive Interaction ... and it resulted in increased sociability which also generalised out from the PI activity to improve 'the quality of initiations and interactions' via 'learning mechanisms that may be similar to those used in typical development'. 

So, does this add to the evidence base for Intensive Interaction [which is directly based on the learning mechanisms seen in typical development] ... well, actually I would say "yes": but only indirectly*, and only for this one particular 'joint attention' strategy ... but I think it is still a yes*.

(*my underlining again - and this time with a bit of added bold!).