A dedicated ‘Reference Guide to Publications’ page on II Institute website

For my Blog this week I wish to draw your attention to a fantastic new page on the Intensive Interaction Institute’s official www.intensiveinteraction.org website. 

There is now a dedicated ‘Reference Guide to Publications’ page with over 40 listed Intensive Interaction journal articles and research papers (each with a full reference; Harvard style if my failing memory services me right) that includes: 

• a quite detailed abstract or summary of each paper’s contents.

• a link to the journal site where you can gain access to the whole paper (sometimes free, mainly not).

• and a Bib-Tex (which I’m not sure what that does, but it looks absolutely tremendous). 

I think this page will be really useful to all those who are keen students of our approach, and it will make it much easier for those students who need easy access to the relevant Intensive Interaction literature for assignments, projects or theses on Intensive Interaction.

You can view this page at: https://www.intensiveinteraction.org/resources/publications-bibliography/

This research page has been made possible by the dedicated work of Katherine Shearer and Ian Harris – we need to thank them so much for this fantastic new resource.

p.s. if there are any further papers that you know of that aren't as yet included, please feel free to alert us to this - there is an email link at the bottom of the page, or you can email details to me at: graham.firth@nhs.net. 

Wired for Communication and how the neuroscience of infancy helps in understanding the behaviours of Intensive Interaction

For my blog this week I am once again summarising a really interesting chapter from the book 'Intensive Interaction Theoretical Perspectives' (Ed: Hewett, D. 2011) that I have been rereading recently. This time it is a chapter by Dr Suzanne Zeedyk: Wired for Communication and how the neuroscience of infancy helps in understanding the behaviours of Intensive Interaction.

According to Dr Zeedyk ‘the psychological and neurological sciences have, over the past several decades, revealed two key insights about human development. These are that infants come into the world already connected to other people, and that the pathways in their brains are literally moulded by the responses they receive from those around them’. 

These findings ‘go a long way towards explaining why Intensive Interaction, and other interactive approaches like it, are effective in nurturing the communicative abilities of individuals struggling to engage with others’, and pointing to an infant's innate communicative behaviours, she states that ‘... a neonate’s ability to imitate is an ‘emotional process’ and ‘imitative exchanges are not acts of copying, but moments of sharing’.

Brain development 

The brain grows ‘more rapidly between conception and 3 years that it ever will again’ and ‘is shaped by the experiences that infants have of the world around them, especially social experiences’. Dr Zeedyk then goes on to explain that there are 3 main stages in brain development, firstly 0-3 years, which is the period of most rapid development, next 5-12 years, when the development ‘shifts to strengthening further the existing connections, a process known as myelination’ and finally during adolescence, when ‘the brain has one last burst of synapse creation ... while sharply increasing its rate of pruning synapses,’ those synapses that ‘are never used, are sloughed off’.

According to Dr Zeedyk though, ‘... play is crucial to neural generation. It needs to be free play: active, unstructured, dynamic, relaxed’.

Intensive Interaction 

Dr Zeedyk states that the scientific knowledge of neural development ‘enrich our understanding of why Intensive Interaction works’. She goes on to list the reach of the approach across many different client groups and states that the approach ‘transcends any specific disorder and taps into deeper qualities that are central to our experiences, as persons relating to other persons’. She goes on to state that that the ‘match’ of body movements within Intensive Interaction exchanges sub-consciously ‘generates trust, intimacy, spontaneously and a sense of safety’ and this ‘process is so fundamental that it applies across all age groups and all diagnostic categories’.

Dr Zeedyk also claims that one way to explain the effectiveness of Intensive Interaction is to see it as tapping into the mirror neuron systems as discovered by Rizzollatti’s Italian research team. Mirror neurons ‘fire both when a person has an experience or observes a similar experience occurring in another person', therefore Intensive Interaction can create ‘a context in which existing capacities can flourish’.

Conceptual rethink: ‘The nature of autism: does Intensive Interaction point towards a richer understanding?’ 

Due to the positive outcomes of Intensive Interaction for people with autism i.e. being able to ‘look at their partner’s face, anticipate their response, laugh, tease and take joy in their partners engagement’ Dr Zeedyk suggests ‘the need for an alternative explanation of autism’. She points to Caldwell’s (2006) ‘sensory account of autism’, where hypo and hypersensitivities are problematic for people with autism, and where an environmental change can reduce distress and allow social and communicative capacities to be demonstrated.

Early diagnosis of developmental delay: how important is it?

Finally Dr Zeedyk states that early diagnosis of developmental delay is ‘incredibly important’, and that due to the scientific understanding of brain development it is possible that ‘we may be unintentionally exacerbating autistic tendencies and learning difficulties’. 

She believes that with very early diagnosis ‘we have a chance to change children’s life courses for the better, to alter their very biology and brain structure’... and that ‘Intensive Interaction lets us, if we let it, begin to really understand the transformative power of emotional connection’.

Powerful thoughts and words indeed!

An ideal Intensive Interaction service?

I was recently contacted by a member of our Intensive Interaction community and asked what an 'ideal Intensive Interaction service' would look like. Well, I think its a good but quite complicated issue to address and succinctly answer. 

I think it is complicated because Intensive Interaction is now used across so many different working and care contexts, with children and adults with differing levels of learning disability, with children and adults with autism, sometimes with people with multi-sensory impairments, sometimes with people whose behaviour severely challenges us and our services in how best to respond; now also increasingly with older adults with late stage dementia.

So I ask myself: is there a single and hopefully relatively simple description of such an 'ideal Intensive Interaction service' that can help define and thus deliver best Intensive Interaction practices across all such diverse care, support and/or educational environments?

Well, I have had a go, and below I set out what I think would be the general characteristics of an 'ideal Intensive Interaction service' that, if achieved or enacted, would create a service that would deliver the most effective Intensive Interaction we could wish for. These are:

• Regular and flexible Intensive Interaction sessions (both timetabled and opportunistic) are offered to the learner/service user (as evidenced in some format of routine recordings).

• Learner/service user engagement in Intensive Interaction is routinely recorded, with details of novel interactive occurrences also routinely recorded, and such recordings made readily available for all staff to see/view.

• At least some Intensive Interaction sessions are routinely recorded (in a range of formats as the identified purpose demands) and staff regularly engage in a structured reflective process (including reflective video analysis) to develop genuinely ‘person-centred’ Intensive Interaction plans and practices.

• All significant staff are trained in and well informed of the Intensive Interaction rationale and practices (including during any initial induction training), with regular training updates or peer discussion and reflection sessions made available.

• There are active medium to longer term plans for continuous staff Intensive Interaction practice development, and all significant staff (i.e. those that directly practice Intensive Interaction) have access to regular peer supervision sessions with more experienced colleagues (or managers).

• The general working or care environment is deliberately arranged in a reflective and ‘person-centred’ way so as to enable Intensive Interaction to readily take place in the best possible way, at every available opportunity.

• All levels of service management are well informed of the Intensive Interaction rationale and practices (ideally there being an identifiable service level Intensive Interaction Coordinator), and take a visible role in the development and direct delivery of Intensive Interaction.

Then I think, is that enough; have I missed something? or is all this naively unachievable? 

Well, what do you think?

What is Intensive Interaction Curriculum, process and approach? a chapter by Dr Dave Hewett OBE.

For my blog this week I am again summarising a chapter from the book 'Intensive Interaction Theoretical Perspectives' (Ed: Hewett, D. 2011) that I have been rereading recently. This time it is the final chapter by Dr Dave Hewett:

What is Intensive Interaction? Curriculum, process and approach

In this chapter Dave (now Dr Dave Hewett OBE!) sets out his perspective on what Intensive Interaction actually is. Below I try to do his chapter justice and set out some extracts from this 'learned' discussion piece (his words ... and mine; you should see the list of references) defining Intensive Interaction as a 'teaching/learning approach'.

Intensive Interaction and process curriculum

Initially Dave sets out his thinking about how to describe Intensive Interaction in curricular terms, and states that ‘... the learners for whom Intensive Interaction is crucial, far from needing a broad and balanced curriculum, instead need one that is rather particular and focused.’ 

Defining Intensive Interaction as a teaching/learning approach

To help define Intensive Interaction, Dave casts Intensive Interaction as a ‘process-central’ approach. He states that: ‘In this model, the learning outcomes gradually emerge over time, as a result of the rolling, cumulative, generative process of frequent, regular, repetitive activities of Intensive Interaction’... and he's right, of course.

He then claims that with Intensive Interaction ‘the teaching, moment by moment, is more by a sense of artistry than by prescription’ (what a beautifully succinct term!) and that it isn’t possible ‘to be precise about when all the learning outcomes emerge’.

He also points out that such a way of teaching isn’t radical, and states that the teaching described in the UK Early Years Foundation Stage (EYFS, QCDA, 2008) guidelines advocate teaching in much the same way, ‘with emergent learning outcomes’, and with ‘little emphasis on prescriptive or objectives-dominated learning’.

Vygostky and the ZDP

According to Dave, the Zone of Proximal Development (ZPD) concept of Vygotsky, and Bruner’s ‘Scaffolding’ conceptualisation ‘have always seemed to be useful thinking tools for allowing for the complexity of the teaching operation within parent-infant interaction and Intensive Interaction’. He elegantly describes the ZPD as ‘a malleable, flexible, questing entity, constantly reforming itself around, or ahead of the sensibilities and gathering powers of the learner’. He also states that in Intensive Interaction the teaching is mainly ‘intuitive and tacit, not necessarily conscious, but also judiciously blended with the conscious, tactical decision’.

Outcomes complexity and dynamic systems

With Intensive Interaction, according to Dave, ‘the learning is so vast and complex, the expert cannot break it down into sequential steps ... rather the complex learning situation gradually makes available the transfer of everything the expert does know, and also provides the dynamic social ecology necessary for the development of the cognitive substructures for the learner’.

The development of these ‘cognitive substructures’ thus becomes visible in the learner developing the understanding and practical skills identified in the ‘Fundamentals of Communication’ (Nind and Hewett, 1994). Although, as he points out, these Fundamentals of Communication (FoC’s) are really just the externally observable ‘tip of the iceberg’. Indeed he goes on to offer the opinion that 'the contents of the learning [in Intensive Interaction] is complex beyond analysis’.

Dave also goes on to contrast linear, task-analysed behavioural approaches to teaching (the most commonly seen type of approach used in special education) and sees these as inappropriate for the teaching of ‘the labyrinthine complexities of communication cognitions and performances’. Instead a more dynamic, play-based, playful and natural teaching approach is required, and he cites the views of Thorp and Gallimore (1988) who state that ‘in every culture, natural teaching transmits skills of immense variety and power - a “curriculum” of far greater complexity than anything attempted in schools’.

With such a view in mind, He notes that for Intensive Interaction sessions, they may feel ‘simple and beautiful to the participants, but they are actually complex and multi-faceted’.

The three ‘R’s and 'spiralling'

Dave nicely identifies the 3 R’s of Intensive Interaction as being: ‘Responsiveness’ ‘Repetition' and ‘Repertoire’ and he asserts that, ‘if the totality of the progress that any individual can make is to be anywhere near attained, the [Intensive Interaction] activities need to be repeated literally many, many times, day by day’ - a situation corresponding to the ‘natural model’ of parent-infant interaction.

However through this continuous process of repetition, the activities ‘gradually expand in duration, they gradually expand in content, they gradually expand in sophistication and complexity’. Finally Dave introduces the concept of ‘spiralling’ to describe the non-linear progress made as activities ‘gradually ‘lift off’ and ‘spiral upwards’ with a sense of the success in the activities breeding further success and so on’.

Anyone and everyone involved in the teaching of students with communication or social impairments should be made to read, and reread (as I did) this chapter. Talk about 'essential reading'!

Intensive Interaction Handbook Book review in an International PBS Journal

For my Blog this week I will draw your attention to a book review in a recent issue of the International Journal of Positive Behavioural Support. 

The review was on The Intensive Interaction Handbook (2018: 2nd Edition) by Sage Publications. The review is from Speech and Language Therapist Nicola Wightman (West Dunbartonshire Learning Disability Service). I think it is great to see the message being put out there to help inform our colleagues in the PBS community about the power of Intensive Interaction as a proactive social communication approach: thanks Nicola! 

Below are some extracts from this review:

Nicola starts by saying that: 'Dave Hewett begins this 2nd edition of The Intensive Interaction Handbook briefly reminding us of the wonderful nature of human communication and how, when it is working well, we can, mostly ‘non-consciously’ read other people. This allows us to tune-in to others on a psychological and emotional level and enjoy ‘social gossip'. 

'This sets the context for the rest of the book, giving a brief overview of Intensive Interaction, what it is, who it is for and what it teaches – the fundamentals of communication. This allows the reader to understand that Intensive Interaction helps meet the basic human need of communicating and being social for the sake of it, and that for some, it will be the building blocks to developing speech and language'. 

Nicola then points out that: 'The vast majority of the book is given over to the practicalities of doing Intensive Interaction – and if this is something you have always wondered about, or if you’ve never been sure whether you’ve been ‘doing it right’, then these chapters will hold your hand the whole way through. If you’re a newbie to Intensive Interaction, you will appreciate the level of detail. If you have more experience, then it will be an excellent refresher'. 

Nicola also said that she ... 'particularly liked the chapter on Doing Intensive Interaction at home (Chapter 11), where Tandy Harrison discusses the use of Intensive Interaction in the home environment. I think the Handbook in general will give parents the background to what I find they, often, are already doing ‘non-consciously’. This is something I would like to see more of because it is so important'. 

Finally Nicola states that: 'This is not a technical book; it is not immersed in the evidence base. If you are looking for a systematic review of the Intensive Interaction literature, this is not for you. It is, as it states itself to be, a practical handbook. It takes us, step-by-step through the how-to of Intensive Interaction; it reminds us of the why and it shows us how to record it. If you are a practitioner out there doing Intensive Interaction, you will find this resource invaluable'.

For the full review see the International Journal of Positive Behavioural Support (2019, Vol 9, Issue 2, p.64-65).

Dave Hewett is appointed an OBE for 'services to people with special educational needs and disabilities'.

Dave Hewett is appointed an OBE for 'services to people with special educational needs and disabilities' in the UK New Year's Honours List (see BBC News website article below).

Dr Dave Hewett is one of the originators  of Intensive Interaction (alongside Professor Melanie Nind). He initially published on the approach as far back as 1988, and has spent most of his working life developing, defining and tirelessly disseminating this approach extensively across learning disability and special education services. 

Indeed Dave continues to this day, despite declining health, to be the main driving force behind the broadening influence of Intensive Interaction in helping people with learning disabilities and/or autism, irrespective of age, degree of impairment and learning or living environment, to have access to genuinely 'meaningful two-way communication' (Valuing People Now, DoH, 2009). He has more recently promoted its use for those suffering from later stage dementia.

Dr Hewett’s publications and presentations, including his many articles, chapters, books, training resources and DVDs (many collaboratively undertaken) have had a enormous impact on the development and implementation of Intensive Interaction. 

Intensive Interaction is now an approach that is used by an extensive range of individuals and professionals including families and carers, teachers, nurses, speech and language therapists, occupational therapists, clinical psychologists and many residential and other care establishments or services. Indeed it is an increasingly important feature of the graduate and post-graduate curricula for many of these professional groups.

Intensive Interaction is now seen to have a wide breath of utility and is used to improve social communication outcomes for adults and children with learning disabilities, autism, acquired brain injury, late stage dementia and, indeed, any individual whose diagnosis involves a social or communication impairment. However, it is important to bear in mind that the people who truly understand the power of Intensive Interaction are those many people who have had personal experience of it, such as families, carers and, of course, service users themselves.

In summation, without Dr Hewett’s tireless and continued endeavours to define, develop and continuously promote Intensive Interaction over the last 30 years, many people would not now have a chance to enjoy and benefit from the positive, affirming, nurturing and socially inclusive engagements that this single approach has made possible.

Directly and indirectly the work of Dr Hewett has had an extraordinarily positive effect on the quality of life of many thousands of individuals with social and communication impairments, and subsequently also their families and carers. I can think of no one more deserving of such an honour.

An NHS 'Observation' policy without mentioning how to interact? ... in 2019? Surely not!

I was recently sent a copy of a newly ratified (in July 2019) NHS policy on 'Procedures for Observation and Engagement' for staff of a NHS mental health and learning disability trust 'in all acute units, inpatient settings and residential areas where service users may be observed by staff'. This policy states that: 'Observation and engagement is a skilled clinical intervention' and that 'Effective observation is underpinned by continuous attempts to engage the service user therapeutically'.

All well and good I hear (imagine) you saying, but below I will list the number of mentions in this 'observation' (which gets 138 mentions!) and 'engagement' (which manages a paltry 19 mentions) policy of the possible 'Fundamentals of Communication' through which any 'engagement' could be developed for service users with communication or social impairments (e.g. because of a learning disability, autism or mental health condition):

So, for 'Interaction' = 0 mentions - so how about, in alphabetical order:

'Attunement' and/or 'tuning in' = 0 mentions 

'Enjoyment' and/or 'pleasure' = 0 mentions  

'Eye contact' = 0 mentions  (although having someone in 'eyesight' = 14 mentions!)

'Facial Expression' and/or 'Smiling' = 0 mentions 
'Joining in with' and/or 'mirroring' and/or 'echoing' = 0 mentions 

'Joint focus' = 0 mentions 

'Sequencing' (as in 'sequencing' communicative actions) = 0 mentions   

'Touch' or 'physical contact' = 0 mentions   

'Turn taking' = 0 mentions.  

Well then, how about 'rapport': well, that got 1 mention as 'therapeutic rapport', as opposed to normal, run-of-the-mill, sociable rapport. 

So how about 'sociable' and/or 'social' ... you're probably there before me = 0 for both!

Even the use of words like 'conversation' and/or 'talking' (i.e. for those who could use symbolic language to develop and sustain some sort of conversational exchange or engagement), for both (oh no, here we go again) = 0 mentions. 

However, 'Activity' does get 6 mentions in a half-page section called 'ENGAGEMENT' where 'Consideration should be given to the use of activity, discussion and distraction techniques ...'. Hardly much there in terms of any useful detail, I'm sure you'll agree.

Now obviously this is a necessary and important area of 'policy' if we want to create therapeutic 'engagement' (remember = 19 mentions) during periods of care requiring some level of service user 'observation' (=  138 mentions). However, to me this 31 page policy is woefully unbalanced in terms of not sufficiently pointing staff to proactive (= 0 mentions) social engagement, and lacking in any useful procedural guidance on how staff should use their 'fundamental communication' skills to enact some form of therapeutic engagement with service users with communication or social impairments. This made me think: 

a) it evidences a particular therapeutic (no, actually overly medicalised) NHS mindset that sees engagement as a specialised professional skill set not naturally available to all staff through the sensitive use of their 'Fundamentals of Communication' (either intuitively, or via some method of training or mentored support) 

b) it is such a missed opportunity to set out how to achieve more sociable 'engagement' and genuine 'rapport' with some of our service users who struggle to use language for sociable or therapeutic engagement (if the two can be truly separated) ... or due to the level of their impairments, have no access to the sociable use of language.

Now, I am in no way calling out any of the genuinely dedicated NHS staff who developed this policy (it is probably just a development of a previous one) ... but to me it evidences a de-personalising institutional perspective that can at times skew how we see (or 'observe' = 138 mentions!) and provided engagement for some of our most challenging service users. 

However, I am not utterly downcast by this. It is my experience generally (and more specifically in the adoption of Intensive Interaction by the brilliant staff on our learning disability inpatient units) that policy tends to follow positive develops in practice, and not the other way around (although often too slowly for my liking). Things are changing, and it is the staff who work directly on the units that are driving this change forward - and hopefully future iterations of this policy will acknowledge and then follow the successful adoption of the more proactive social engagement strategies of Intensive Interaction.

p.s. Wishing you a merry and interactive Xmas and New Year!