'Interactive approaches to teaching and learning' by Dr Penny Lacy

 Interactive approaches to teaching and learning 

For my blog this week (which are becoming much more infrequent I know, sorry about that) I am summarising a chapter by the late and sadly missed Dr Penny Lacy from the book:

'Intensive Interaction Theoretical Perspectives' (2011) edited by Dave Hewett, Sage Publications, London. 

There is some belting stuff in it!

According to Penny ‘Interactive approaches to teaching and learning ... developed in the UK in response to the prevailing dominance of behavioural approaches in the 1980’s’. She notes the concern prevalent at the time that skills were being taught that did not lead to an understanding of ‘when, where and how to use those skills’, and the skills could only be reproduced ‘in that one [classroom] context’. 

She then goes on to cover some of the history of the development of ‘interactive approaches’ and how difficulties arose due to the adoption of the National Curriculum and the prevailing ‘target driven agenda’. Lacey identifies interactive approaches as influenced by ‘the processes of education rather than by the products’, and such approaches encouraged teachers to consider the importance of ‘intrinsic rather than extrinsic rewards’.

Penny states that: ‘Interactive approaches have their routes in cognitive psychology and a desire to understand the development of such processes as thinking, perceiving, reasoning, judging, problem-solving as well as the development of communication and language’. Within interactive approaches children are viewed ‘as being active in their own learning’ and this active engagement ‘lifts learners from ‘learned responses’ to ‘intelligent behaviours’’.

Interactive approaches also support learners in ‘taking control of their own learning’ allowing learners to ‘gradually understand that their actions are the causes of the effects they can see, hear and feel’. She also points out that in the early stages, ‘3 components of learning appear to be important ... exploration, imitation and repetition’ and these are ‘all part of active learning and enable young children to become increasingly autonomous’.

Penny then looks at some theoretical views of learning and language acquisition, initially pointing the reader to Piaget’s theories of the child ‘developing ideas and concepts through trial and error’. She also points to the work of Vygotsky (he of the Zone of Proximal Development or ZPD) who viewed ‘learning and development to be mutually dependent and interactive’, and that ‘learning needs to be organised and structured by teachers to provide an environment within which children can derive the most benefit’ ... ‘children need an environment ... that is interactive, where people around them talk to them, listen to them and generally encourage all attempts at communication’.

Penny also goes on to look at learning through play (for young children) and how adults need to ‘enhance’ the learning of children without ‘taking over’ i.e. they need to ‘take the lead from the child, rather than being didactic’. However, she acknowledges this kind of active exploration and learning can be very difficult for children with profound and multiple learning difficulties (PMLD), who may also have multi-sensory impairments (MSI), and severe physical and motor impairments, and thus, in such circumstances adults, ‘may need to take a much more leading role’.

She also points out that for children with PMLD ‘progress is likely to be extremely slow’ and they need ‘... a huge amount of repetition’ for learning to accrue. She then advocates the use of the ‘Routes for Learning’ assessment tool (Welsh Assembly Government, 2006) which provides 43 different behaviours (for communication and cognition development) that can be assessed and suggests strategies for moving children on to each behaviour. 

Finally, Penny points us to Alexander (2006) who defines ‘what makes universal good teaching’, i.e. that teaching is:  well organised and planned; reflective; is based on sound subject knowledge; depends on effective classroom management; requires an understanding of children’s developmental needs; uses exciting and varied approaches; inspires; encourages children to become autonomous learners; facilitates children’s learning; stimulates children’s creativity and imagination.

A qualitative study of the practice related decision making of Intensive Interaction Practitioners

'A qualitative study of the practice related decision making of Intensive Interaction Practitioners' 

by Graham Firth, Megan Glyde & Gemma Denby 
(with thanks also to Emily McGall and Cheryl Campbell)

The aim of this qualitative study was to investigate the sometimes conscious and sometimes ‘intuitive’ or unconscious decision making processes of Intensive Interaction practitioners. Through interviewing 13 experienced practitioners (all qualified Intensive Interaction Coordinators), this study set out to shed some useful light on how practitioners make judgements when developing 'a dynamic interactive repertoire' with an individual with severe or profound learning difficulties and/or autism.

The main conclusions drawn from this study (hugely paraphrased for brevity!):

The study found that practitioners co-constructed 'a mutually recognised interactive repertoire' with the people then engaged through Intensive Interaction, but also that 'their understanding and consequent enactment of their own practices' evolved through a cycle of:

1. Some pre-engagement considerations: focusing on aspects of the practitioners’ learning or care ‘agenda’ and expectations, possibly with some proactive environmental preparation (including any required changes to the social or physical environment).

2. Some ‘trial and error’ experiential learning: during each engagement (including at the initiation and disengagement phases), this often being based on the practitioner’s ‘in the moment’ decision making (often intuitively but at times consciously considered) that elects to follow or offer particular variations on any established interactive repertoire. Such ‘in the moment’ decisions being concurrently reflected on ‘in action’ by the practitioner in the light of the person’s perceived feedback responses to their interactive offer, either positively so, or otherwise.

3. Some post-engagement conscious reflection: conducted either individually or collaboratively, sometimes involving informal or more structured reflective processes, and focused on either individual practice or developing a greater understanding of broader and thus more general Intensive Interaction principles, or both.

To cut a quite long (but very interesting) story short for this blog, we go on to conclude that:

'Without a clear process to support reflection on our experiences, we are unlikely to develop our Intensive Interaction practices, both individually and collectively, to their full potential.

‘Anybody only gets that [improved Intensive Interaction practice] through reflection and looking at the videos and chatting about it with your staff; nobody’s an expert, we all need each other’s eyes to support each other’ (Practitioner verbatim text extract: #2, 243-245)

'Services that purport to use Intensive Interaction therefore need to create a supportive and nurturing developmental process within which novice practitioners can learn the skills, principles and knowledge required to practice good quality Intensive Interaction – and they need to do this to effectively and consistently provide the people they care for or support with genuine social inclusion and appropriate developmental opportunities to enhance their social communication and connectedness to maximum degree possible'.

(In some of my following Blogs I will lift various more focused aspects out of the main report to illustrate some more detailed areas of practitioner decision making as it relates to particular issues, or temporal aspects, when using Intensive Interaction).

For a copy of the full (and really very interesting) initial draft report, please email: 

graham.firth@nhs.net

Social touch and disordered development: autism

Following on from my previous Blog on 5th September ('Social touch and human development' ... an interesting paper) reporting on the paper 'Social touch and human development' by Cascio, Moore, & McGlone, in this Blog I will focus on one important aspect, this being 'Social touch and disordered development: autism'.

What the authors say about touch and how it more specifically relates to people with autism is I think highly significant. They make the following points:

• The impact of social touch on the developing brain and the consequences of its altered trajectory in childhood are indicated as being 'highly relevant for autism spectrum disorder'. 

• Children with autism 'exhibit aberrant behavioral responses to touch which are strongly linked both with the core clinical symptoms [of Autism] ... and genetic variants that increase serotonin transporter function'. 

• 'Experimenter-delivered affective (pleasant and unpleasant) touch to children with autism elicits defensive reactions that are more severe in CT-innervated somatotopic regions [i.e. touching their face or arms] than in non-CT-innervated regions [e.g. touch to their palms]' - which is an interesting finding, if it is generalisable to the more general autistic population! 

• 'Taken together, these results indicate that social touch is altered in autism', although the authors do say that it isn't yet clear how this impacts on individuals with autism who experience specific forms of 'hyper-responsiveness and hypo-responsiveness'. 

• The authors also go on to say that: 'Both hypo-responsiveness and hyper-responsiveness to social touch may result in reduced input (occurring naturally or resulting from defensive/avoiding behaviors) that alters the trajectory of the developing social brain starting in infancy'.  

• Then perhaps most importantly the authors state that: 'Given the fundamental importance of social touch for infant’s formation of secure attachment, cognitive and linguistic development, social reward, and emotion regulation, these differences are likely to have far-reaching effects'. 

The authors finally sum up with the vitally important statement that: 

'A better understanding of these sensory-social developmental sequelae (i.e. the developmental consequences of the altered touch related neural responses of individuals with autism) holds great promise for developing and refining early intervention approaches based on sensory features'.

The sooner the better I would suggest.

Intensive Interaction: 'A tool for communication', OTnews article (May 2019).

My blog for this week is shamelessly referencing (or mainly copied from) a recent article in OTnews (the official monthly magazine of the Royal College of Occupational Therapists). In this article, 'A tool for communication', Rebecca Haythorne (an Occupational Therapist at Leeds & York Partnership NHS Trust), discusses the role of Intensive Interaction in facilitating meaningful engagement for one of her NHS service users with a learning disability and autism.

Below I sample some of her article in the hope of giving an Occupational Therapy view of using Intensive Interaction integrated into aspects of their own case work:

'John, a 26 year old man with learning disability and autism, lives at home ... and receives care 5 days a week to support engagement in activities of daily living and meaningful occupations ... He was referred for occupational therapy input after concerns were raised that he was finding it difficult to engage with his care team and was spending a significant amount of time in his bedroom area'.

'After an initial assessment of needs, it was agreed that the Occupational Therapist would work with John and his support team to explore a range of interventions and approaches to support his care team to engage him more positively in purposeful and meaningful occupations ...'

'The Occupational Therapist worked with John and his care team over a period of five months, and during this assessment period it was identified that Intensive Interaction was a positive and key approach in supporting him to engage in both domestic and leisure activities in and outside of the family home'.

'One of the key objectives of exploring the Intensive Interaction approach with John’s care team during times of intervention was to identify and demonstrate the value and importance of engaging John in less demanding activities that occupy his time, as opposed to more physical observable and measurable ones'.

During the assessment process 'the Occupational Therapist observed that John was sat in the window seat at his home and was refusing attempts made by his care team to engage in activity. The Occupation Therapist noticed that John was occupying his time by watching the council maintaining trees. This was seemingly a purposeful activity for John, and through carrying out Intensive Interaction techniques of sitting with John, mirroring his actions when he communicated interested, and letting John lead the activity, the Occupational Therapist was able to reduce the demands that his care givers were placing on him to do an activity that they thought was more purposeful'. 

'Through reducing the demand being placed on John and following his lead and pace the Occupational Therapist was able to support John from moving on from this activity into the next activity of his choice in a timely manner'. 

'To conclude, Intensive Interaction can be a positive tool to support occupational therapy interventions to increase engagement in meaningful occupations and activities for individuals with complex needs ... In this case, the Occupational Therapist used Intensive Interaction approaches to emphasise to his care team that engagement in ‘activity’ should not be based on one action after another to keep him physically active, which can often cause a demand overload. Instead it should be measured by the quality of the intervention offered to occupy the service user’s mind in something that he finds purposeful'.

'Social touch and human development' ... an interesting paper.

I would like to thank my most estimable colleague Lynnette Menzies for pointing me to an interesting paper on: 'Social touch and human development' by Cascio, C., Moore, D. & McGlone, F. in the journal Developmental Cognitive Neuroscience, (2019, vol 35, p.5-11).

In this paper the authors talk about how sociable physical contact 'is a powerful force in human development, shaping social reward, attachment, cognitive, communication, and emotional regulation from infancy and throughout life'. So, already I am interested, although this claim probably sounds very plausible (bleeding obvious) to most of the people reading this blog. 

However, when getting into the main part of the paper the authors go on to discuss issues such as there being two different touch systems (or 'sub-modalities' of touch) that mediate between 'affective touch' and 'discriminative touch', and how 'factors such as culture, personal relationships, setting, gender, and other contextual influences are also important in defining and interpreting social touch'. They also note how touch can be 'associated with immediate reductions in both behavioural and psychological response to stress'.

Without copying (or 'referencing' as I like to call it) the entire paper, I thought I might point to some of the issues accounted for in the paper's conclusions, where the authors state that:

• The 'developmental nature' of social touch is 'dynamic, integrative, and firmly rooted in reward learning processes that shape the developing brain and ultimately adult behaviour'.

• 'The landscape that defines social touch changes qualitatively from an intense and primary mode for associative learning and affiliative connection in the earliest stages of pre- and neonatal life, to part of a multisensory integrated environment throughout the lifespan'.

• The 'perceptual experience' of social touch 'is in and of itself the product of several overlapping integrative processes ... [and] is paired repeatedly over time with physiological and psychological processes that invoke feelings of comfort, security, and satisfaction' (- my underlining for the purpose of extra emphasis). 

• Such overlapping, integrative neural processes 'in the central nervous system are effectors of broader neurobiological systems including oxytocin and mu-opioid systems mediating the reinforcing properties of simple and more complex social bonding' (- again, my underlining for extra emphasis). 

• Finally the authors state that these integrated 'social touch' neurobiological systems 'all interact with top-down contextual factors, including the nature of the relationships, culture, and social context, to create a highly complex, flexible platform in which the rich affective information conveyed through the skin exerts a powerful impact on behaviour ... over a lifetime' (and again, my underlining for extra emphasis).

I am sure we've* been saying much the same thing (although maybe not using all the same words like 'innervation' or 'myelinated' or 'somatosensory') for years now! 

So remember, the next time someone asks you about your use of touch as part of your Intensive Interaction practices, you can tell them all about how: 'the overlapping integrative processes ... in the central nervous system are effectors of broader neurobiological systems, including oxytocin and mu-opioid systems, mediating the reinforcing properties of simple and more complex social bonding' ... or you can just say it is one naturalistic element of the now well established Intensive interaction 'social' communication approach (see *Nind & Hewett, 1994, 'Access to Communication' p.24 - again, my underlining for extra emphasis).

The evidence for Intensive Interaction reducing Challenging Behaviours?

I and a number of my colleagues here in Leeds have just submitted a paper for publication looking at the successful use of Intensive Interaction with service users admitted to our Trust's learning disability Assessment and Treatment Unit - these service users generally exhibiting some form of severe challenging behaviour. I believe that this paper makes a very strong case for using the approach with such service users. 

However, when writing up this paper it was difficult to find much in the way of other published research evidence of any direct relationship between the use of Intensive Interaction and a decrease in the frequency and severity of challenging behaviour - despite there being a huge amount of anecdotal evidence of many successful cases (including my own very extensive professional experience when working with such service users).

In a paper published in 2012 (Sharma, V. & Firth, G. (2012) ‘Effective Engagement through Intensive Interaction’, Learning Disability Practice, 15 (9), 20-2) we looked for and found only a limited number of peer reviewed journal articles providing some (also limited) evidence of positive challenging behaviour outcomes directly linked to the use of Intensive Interaction. These articles included:

Zeedyk, Davies, Parry & Caldwell (2009) who taught Intensive Interaction to 12 volunteers at a Romanian day centre for children with varying physical and cognitive disabilities. The results indicated a decrease in distress and self-harm behaviours in 39% (7) of the children. However the claims in this paper were methodologically weakened as there was no assessment of the prevalence of the challenging behaviour prior to the use of Intensive Interaction, and the post-intervention assessments were based only on the volunteers’ stated views.

Kellett (2003) offers a more methodologically robust study. Her research participant (aged 8) was observed over a 5 weeks baseline, followed by 42 weeks of Intensive Interaction. Over the Intensive Interaction sessions the challenging behaviour reduced significantly from an average of 15.8 recorded incidents pre-Intensive Interaction, to 1.34 incidents post-Intensive Interaction.

However, in contrast Elgie & Maguire (2001) recorded no observable change in their participant’s self-injurious behaviour (SIB), despite improvements in sociability (in comparison to baseline measures), although the researchers suggested this was due to the participant being in the early stages of intervention, and that she had been self-harming for most of her life.

In our paper we concluded that: 'Overall the limited research offers tentative support to the hypothesis that Intensive Interaction can be effective in reducing the severity and frequency of challenging behaviour' in individuals with severe or profound and multiple learning disabilities. We also said that what research there has been 'suffers from a variety of methodological limitations, including small samples and a lack of objective assessment pre- and post-intervention. Furthermore there appears to be a lack of measures to account for procedural integrity over what type and how Intensive Interaction was performed'.

This is now an area within which Intensive Interaction is often used (and in my experience very successfully) - but it is an area that I believe is chronically under researched (perhaps you can identify some more recently published papers: I do hope so!) ... and surely this is a state of affairs that needs to be rectified. 

Elgie, A. & Maguire, N. (2001) 'Intensive interaction with a woman with multiple and profound disabilities: a case study'. Tizard Learning Disability Review. 6, 3, 18-24.

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, 1-16.

Sharma, V. & Firth, G. (2012) ‘Effective Engagement through Intensive Interaction’, Learning Disability Practice, 15 (9), 20-2.

Zeedyk, M., Davies, C., Parry, S & Caldwell, P. (2009) '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.

'Intensive Interaction seems a logical and obvious approach to fostering and developing communicative and social abilities in a learner-led, naturalistic way' Lydia Swinton (2012)

Sometimes when we do our training, we leave out a range of books and packs for trainees to look at during coffee and lunch breaks. One such book is Intensive Interaction: Theoretical perspectives (2012), and in it is a extremely well researched and referenced chapter on 'Intensive Interaction and its relationship with the trial of impairments in ASD' by teacher Lydia Swinton. It is still well worth a read, as the extracts below attest.

Intensive Interaction and its relationship with the trial of impairments in ASD by Lydia Swinton in Intensive Interaction: Theoretical perspectives (2012) Sage.

The author begins by acknowledging that people with ASD have ‘a range of individual differences’ and identifies ‘the vast complexity of trying to teach social skills [to people with ASD]’. She also succinctly relates a view that her experience ‘of the approaches used to teach individuals with ASD did not seem to incorporate any means of teaching these social skills or, if they did ... it was in a manner which seemed artificial and formulaic’.

The author applauds a recent ‘greater focus in these [neurological and non-conscious] areas’ and states that ‘the findings of neurological research are beginning to reflect the ‘gut feeling’ nature of Intensive Interaction’. She goes on to add ‘practice that was initially led by empathy and instinct is now being supported by neurological reality’.

The Fundamentals of Communication and what is taught/enhanced through the use of Intensive Interaction

Here Swinton states that ‘The link between the outcomes of Intensive Interaction activities and the potential impact of these outcomes upon the triad of impairments is not in any way radical or improbable’. Instead, she states that ‘Intensive Interaction seems a logical and obvious approach to fostering and developing communicative and social abilities in a learner-led, naturalistic way’. 

Intensive Interaction 'also addresses these issues with more depth and richness than any of the other currently used ASD approaches, focusing on areas of communicative development which are not often attended to by the more structured, teacher-led methods’. She goes on to state that Intensive Interaction ‘seems to be an approach refined to the complexity of the communication impairments’ experienced by people with ASD.

How the Fundamentals of Communication work alongside the triad of impairments

In this section Swinton explores some of the research into the use of Intensive Interaction with people with ASD, and suggests that its usefulness lies in the fact that with Intensive Interaction ‘the learner is enabled to have a meaningful role within an interaction, without the pressure to communicate in a ‘typical’ way’.  She then focuses on the use of imitation, which she describes as ‘a starting point to develop awareness of self and other' and ‘can increase eye contact, gesture and touching in children with ASD, as long as it is child-led’.

According to Swinton ‘initiation of communication’ is also important, and according to the National Research Council ‘... interactive styles of teaching which offer initiation of communication activities have more beneficial long-term effects on the progress of children with ASD’. She then discusses the Intensive Interaction principles of ‘viewing stereotypical behaviours as having potentially communicative functions’, ‘tasklessness’ and ‘tuned-inness’, seeing these aspects of Intensive Interaction practice as providing the learner with ‘a customised, synchronised and fully sensitised communication experience ... providing a ‘good fit’ between the teachers input and the learners needs’.

However, the author offers a note of caution when stating that ‘while the developmental, learner-led ethos of Intensive Interaction is frequently lauded, it often does not seem to translate into general practices in services’ ... and that the impact of Intensive Interaction in the ASD field ‘should be more acutely realised than it currently is’.

Resolution

In the final section Swinton compares Intensive Interaction with other autism-specific approaches (TEACCH, CHAT, PECS) which she says ‘focus on a rigid, highly structured way of teaching and assessing these very complex, sophisticated and, at times, surprisingly diverse skills’ and ‘do not even appear to address’ a learner’s social communication difficulties. In contrast, according to Swinton, ‘Intensive Interaction allows the development of the messy, jumbled and unique process of learning to communicate and socialise, without placing demands or restrictions upon the learners’.