Stereotyped behaviours ... and how they should 'be seen in the context of concern with the whole person'

Having recently set out some guidelines on working with someone with a range of potentially socially isolating self-involved or self-stimulatory or stereotyped or repetitive/perseverative behaviours (various people, from various backgrounds, can and do label these behaviours in various ways) and advocating that staff should find ways to positively join in with them, I then found myself re-reading some interesting stuff by Melanie Nind and Mary Kellett.

This really powerful stuff looked at professional's (whoever they might be) views of some people's 'stereotyped' behaviours; and also how those working through Intensive Interaction might alternatively see them, and more importantly how we (as II practitioners) might subsequently positively respond  to these behaviours - this I think being at the very heart of the, for some, very radical nature and values of Intensive Interaction. I reproduce some of it below:

'Traditionally, professionals working with individuals with severe learning difficulties who demonstrate stereotyped behaviours, such as rocking and hand-flapping, have viewed such behaviours as undesirable, inappropriate and in need of reduction or elimination. This perspective is influenced by notions of readying those individuals for mixed settings, educating, training or modifying them to help gain their acceptance. Intensive Interaction is an alternative approach for working with individuals with complex difficulties that responds positively to them and their stereotyped behaviours, sometimes using these as a point of connection.'

(Abstract: Nind, M. & Kellett, M. (2002) Responding to individuals with severe learning difficulties and stereotyped behaviour: challenges for an inclusive era, European Journal of Special Needs Education, 17(3), 265-282.)

They then go on to say: 'Intensive Interaction sets out to enhance social and communication abilities and not to reduce stereotyped behaviours. However, findings from two studies of Intensive Interaction ... show some reduction in stereotyped behaviours are reported and discussed' [in their 2002 paper cited above]. 

So, it is because we (as Intensive Interaction practitioners) show value to the whole person, and sensitively and positively respond to such stereotyped behaviours, that subsequent to that, they might naturalistically/indirectly reduce as joint, mutually enjoyable and socially interactive behaviours increase.

In the same journal issue Melanie and Mary also responded to some other academics' responses variously critiquing [both positively and negatively] their articulation of the Intensive Interaction approach (crikey they must have been busy!); again I shamelessly reproduce some of this below: 

'We do not regard concern with stereotyped behaviours as redundant ... but we do maintain that the behaviours need to be seen in the context of concern with the whole person ... The worth of people with learning difficulties is neither negotiable nor dependent upon any particular set of behaviours ... The pressure felt by staff, supporting children and adults in ordinary community settings, to have them behave ‘normally’ is very real to them ... We have to live with the tension of valuing people as they are and wanting developmental change for them; how we respond to them as people is how we show our value of them. The issue is one of unconditional positive regard; people who have stereotyped behaviours should not have to alter them to gain our positive regard*'

Nind, M. &  Kellett, M. (2002) 'Response' by Melanie Nind & Mary Kellett to 'Commentary on: Nind & Kellett (2002)' by  Goldbart, J./Harris, J./Hogg, J. in Eur. J. of Special Needs Education, 17(3), 299–300.

*My underlining for emphasis! ... and I think I need say no more!

Intensive Interaction and Conventional Interventions: what is Different?

I was recently asked by a colleague for a copy of a piece of work that I have variously used across a number of different training presentations - this work looks to set out what is different about Intensive Interaction when compared with other more conventional 'interventions' (i.e. ways of working which would have previously been seen as more standard practice) used when working with, or supporting people with communication or social impairments. 

This 'What is different?' list is the work of the most estimable Dr Mark Barber (he of Intensive Interaction Australia), and I think this list is both useful and interesting, especially so in helping define what Intensive interaction actually is in terms of it's general rationale; and I shamelessly share it with you below (as possibly the easiest blog I've ever done):

What is different? Conventionally, an intervention begins by assessing the person to identify what skills are absent or problematic, or which areas of the person’s performance require intervention.

-  Using Intensive Interaction, observation is aimed at identifying strengths and preferences, so that these become the context for social encounters. 

What is different? Conventional styles of intervention and teaching are characterised by practitioners deciding on a predicted outcome or objective.

-  Intensive Interaction is characterised as open ended – the outcome of an encounter is not predicted or aimed towards. 

What is different? Conventionally, the practitioner leads and controls an interaction, engaging the person in a planned ‘teaching’ or ‘learning’ session.

-  Using Intensive Interaction the practitioner makes themselves available for social activity: Intensive Interaction = partnership. 

What is different? Conventionally, the practitioner leads by providing the focus of interest, attracting the person’s attention into joint focus [usually around an object or structured activity].

-  Using Intensive Interaction the practitioner looks for and responds to the person’s focus of interest by actually joining in with it. 

What is different? Conventionally, the practitioner has control over the place, the subject and any reward associated with an experience.

-  Using Intensive Interaction the choice of place depends on the preferences of the person, there’s no need for a reward –because the activity [or subject] of the interaction follows what s/he is already doing there’s no need for a reward……..its enjoyable for the learner [that’s why s/he is doing it] 

What is different? Conventionally, stereotyped or self-involved behaviours are seen as negative or ‘inappropriate’, and can become the focus of an intervention.

-  Using Intensive Interaction stereotyped or self-involved behaviours are viewed as probable ‘access points’ or indications of a means to enable ‘social’ activity. 

What is different? Conventionally, interventions focus on assisting the person to elicit developmentally helpful behaviours from those around them [usually staff].

-  Using Intensive Interaction contingent interactions are a starting point, although the goal of progress up an ‘interactive spiral’ is the same [Nind & Powell 2000]. 

What is different? Conventionally, interventions frequently focus on teaching new skills or developing a new behavioural repertoire.

-  Using Intensive Interaction practitioners engage the person by joining in with their existing behaviour, encouraging them to use skills they already have.

There, I told you it was both useful & interesting! and you can view more of Mark's work at:

www.drmarkbarber.co.uk

Using Intensive Interaction with people with language in residential settings: Some Simple Dos!

Following on from last week's blog about the 'Simple dos' when using Intensive Interaction with people with language in educational settings (04/06/18) developed by those attending our most recent Intensive Interaction Weekend Workshop, here are some 'simple dos' that can be used to inform practitioners when using Intensive Interaction with people with language in residential settings:     

                 

·    Do join in with the person’s interests, actions and vocalisations as a vehicle for an Intensive Interaction engagement – including the use of repetitive words, and see any spoken language as an additional element of the Intensive Interaction, but not the main focus or aim of the Intensive Interaction.

·    Do sociably ‘join in with’ the person’s language – as opposed to just reflecting it back!

·    Do playfully explore the language; the sounds, the emotions, the interaction, the feel, the vibration, the mouth movement and the meaning – but don’t focus on the literal meaning of the language, or on expanding on the literal meaning of the language.

·    Be aware that the words might not have the same meaning for the listener as they do for the speaker - the subjective meaning of words is not always as obvious as the meaning behind some behaviours … but sometimes do offer an extension when the word apparently has clear meaning …

·    Do use your knowledge of the person to know how much language to use (possibly using language only minimally) … and do provide sufficient processing time for the person to fully participate (again by possibly using language only minimally!).

·    Do closely observe the person for feedback as to whether ‘joining in’ the conversation by saying the person’s words back to them would be okay (i.e. not be interpreted by the person as in some way demeaning). We might say back some key words (from a longer utterance) as we  take a turn – but not the whole utterance.

·    Do make the language one of the fundamentals of the communication (e.g. the same as with an object) and follow Melanie Nind’s 5 key elements of Intensive Interaction (from her seminal 1996 paper 'Efficacy of Intensive Interaction' -  more about these in an upcoming Blog!).

·    Do consider the person’s sensory needs and their arousal levels or levels of anxiety … so consider the need to possibly offer a stimulating or calming type activity at the start or end of a session, or consider the inclusion of a sensory item to facilitate a calm, alert state of arousal.

·    Do get Intensive Interaction into communication passports, funding reports, care plans, etc. and do discuss the benefits of Intensive Interaction with management, CQC, etc.

·    Do keep it simple, and do follow your interactive instincts!

So thank you again to all our II Weekenders yet again for all their insightful efforts!

p.s. - you can now 'follow' this blog by clicking the 'follow' button on the top left - somehow Sheridan got there before I even put it up - why not join her and click on 'follow'!

Using Intensive Interaction with people with language in educational settings: Some Simple Dos!

At our recent Intensive Interaction Weekend Workshop in Malham (UK), all the weekenders contributed to writing up some simple 'dos' i.e. practical pointers that can act as accessible advice on how to use Intensive Interaction with people with language; the list below being developed by those working within educational settings (the next blog will have a similar list from those working in residential settings - although there are obviously many overlaps).

So: Some simple 'dos' when using Intensive Interaction with people with language in educational settings:

·   Language should be seen as an additional communicative “vehicle” through which to develop and sustain an Intensive Interaction engagement, with any language use seen as additional to, and not a distraction from, the use of the ‘fundamentals of communication’ (e.g. vocal intonation, facial expression, eye contact, posture and body language, etc).

·   Use good observation and reflection to gain insight into the student’s language use (including scripts); use this insight to inform the responsive use of language with them, remembering that sometimes it might be right to use no language!

·   Allow the student to lead the interaction; be available and respond when an interaction is naturally initiated or develops, and ensure that mutual enjoyment is the ‘focus’ of the interaction (and not any activity or linguistic agenda).

·   Be interested, enthusiastic and flexible in your use of language, but keep the tempo of language attuned to the tempo of the student’s language use and emotional state - allow for processing time; be comfortable with pauses and silence.

·   Enjoy verbally playing with sound, rhythm, volume, and intonation, as well as any words or phrases – and at times, when it feels right, look to gently and sensitively extend (i.e. spiral up) the language use.

·   Ensure that the language use does not put demands or expectations of language performance on the student (e.g. to respond in certain ways), nor create an external agenda that detract from the ‘taskless’ nature of the interaction.

·   Remember the language use may not have any clear or shared symbolic meaning i.e. a student’s language may not be used in a literally symbolic manner, and it may also not be directly indicative of or related to their current emotional state.

·   Use activities or objects of specific interest to the person if they create a familiar and safe social context, and an open-ended structure within which to scaffold the interaction, but always keep the focus on the sociability aspect of the interaction.

·   When appropriate provide sensitive ‘verbal commentaries’ (on shared activity or on any shared visual or auditory focus) to extend sociable language use.

·   Initially have one practitioner build up a trusting relationship with the student; they can then share their Intensive Interaction experiences and practices with others (via workshops, etc) to ensure consistency of approach in all settings.

·   Provide specific training and coaching through the use of videos, modelling, and discussions and make explicit reference to Intensive Interaction in all appropriate documentation e.g. ECHP, IEP, and Communication Passports.

So thank you to all our 'II Weekenders' yet again for all their insightful efforts!

When 'recording' Intensive Interaction engagements, whose attainment are we actually 'recording’?

This Blog follows on from my last two: the first setting out my view on our collective potential to 'unconsciously and unquestioningly project too much confidence into a set of sometimes quite crude numbers' (14/05/18), and the second on the issues I thought important to consider when setting out to 'record' or collect data on the use of Intensive Interaction e.g. the proposed audience, the efficiency, the range of applicability, the scope to capture all levels of developmental progression, etc (21/05/18) .


However, as I was writing these blogs, and generally when I discuss 'recording outcomes' (and services are undoubtedly under ever more pressure to record 'outcomes' of educational and/or therapeutic interventions) I always wonder exactly whose 'outcome' or 'attainment' it actually is that ends up being recorded ... because obviously there are always two communication partners involved in any Intensive Interaction engagement (No s**t Sherlock! as I like to say).

So that poses us a question - are we measuring the individual attainment or social communication outcome of the person we are working with (the learner or service user, or family member) or are we measuring the quality of the Intensive Interaction practice of the practitioner which will support or scaffold the social communication attainment of the person we are working with? ... or more likely, actually almost certainly, some combination of both? 

And if it is some combination of both, how much weight should we give to any perceived individual attainment of the learner, service user or family member, compared to the level or quality of the Intensive Interaction practiced with them? ... interestingly (well, to me anyway) this view also links to my previous blogs of 19/03/18 and 26/03/18 about the level or degree of someone's social impairment being mediated by the good social engagement practices of those supporting them!

This is often where the strong driving force of service/organisational need to record everything as an individual attainment or outcome, often in terms of crude and poorly defined numbers, rubs up badly against any sensible person's more rounded view that all social attainments or outcomes are, and can only ever be, the product of social engagements between more than one individual person.

However, those of us who have the pleasure of working in services (educational, residential, clinical) will be required to input some 'recordings' of some data into some system (increasingly electronic) ... as if it were an individual attainment or outcome. So what do we do ... how do we best play the system to get the genuinely best individual outcome for our people i.e. continuous access to good quality Intensive Interaction? 

That is a difficult question to answer precisely, but I suppose the best way generally is to record attainment and/or outcomes as individual achievements (as required by the system), but to do so secretly knowing that any such 'individual achievement' can only be made real within and through regular Intensive Interaction of the highest quality ... the better we are as practitioners, the better the quality and/or effectiveness of the Intensive Interaction, the better supposed individual attainment or outcome for the individual learner, service user or family member ... I think.

 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!).