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!

Intensive Interaction emotional development and emotional well-being: by Melanie Nind

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 chapter by Professor Melanie Nind: 

Intensive Interaction, emotional development and emotional well-being 

In this chapter Melanie Nind (now Professor of Education and Director of the Centre for Research in Inclusion at Southampton University) sets out a perspective on Intensive Interaction being concurrently both educational and therapeutic in nature, addressing the important and interrelated issues of emotional well-being and development. 

Initially Melanie relates a little history, pointing to the fact that their students’ emotional well-being was not one of the issues they were thinking about when Intensive Interaction was first developed. However, she then goes on to point out the recent emergence of the concepts of ‘emotional intelligence’ and ‘emotional literacy’, and states that emotions are ‘a crucial and integral component of self development’, and are seen ‘to emerge in the interactions between children and their social surrounds’. She also states that ‘emotions are embedded in the interactive space’ and this explains ‘how intertwined the emotional, social and communicative essentially are’, and therefore Intensive Interaction ‘unconsciously yet actively fosters emotional development’.

Melanie points us to 'theories of emotional development in infancy', referencing Dr Suzanne Zeedyk who argues that ‘intense emotional engagement between mothers and infants is regarded as the best foundation for later development’. She then goes on to draw on studies in developmental psychology, including Dynamic Systems Theory, which doesn’t define emotions as ‘discrete states’ but sees them as dynamic ‘coherent emotion patterns that support infant’s meaningful relationships with others’.

According to Garvey & Fogel (2008) emotions emerge through communication and ‘help punctuate the dynamic flow of communication by opening (or closing) opportunities for individuals to experience themselves in relation to others’, hopefully in ‘a mutually enjoyable and satisfactory experience’ (i.e. via Intensive Interaction). Therefore, through being active agents in interactions, both parties can reciprocally foster ‘a sense of connection with and differentiation from others’, thus building an emotional repertoire. 

Melanie then points to a social-biofeedback model (Gergely & Watson, 1999) which sees infants becoming aware of their emotional dispositions through ‘social mirroring’ i.e. contingent reflections of their own emotions by caregivers ‘modulating the infants affective states before the infant develops mechanisms to do so’. Melanie points to Zeedyk again who, when considering the Intensive Interaction strategy of contingent imitative responding as a powerful means of creating emotional intimacy, states that ‘imitation provides the closest correspondence between self and others!’. She then goes on to discuss the role of touch, which Montagu (1986, 1995) identifies as ‘fundamental to health, well-being and cognitive development’; touch having ‘a deep emotional and psychological significance’ and is ‘a primary means for providing comfort and for communicating empathy’. 

Melanie also looks at 'Attachment Theory' (Bowlby, 1969), stating that the attachment experiences of an individual are 'hypothesised to impact on the individual’s later relationships’, as individuals build ‘internal working models’ of their primary relationships (and how to regulate their associated internal states), with good attachment states creating a ‘relational place of safety’. She then relates how Intensive Interaction has helped parents feel ‘newly connected to their children’, and also advises a ‘team approach’ to prevent potential attachments that, if broken, might cause ‘isolation and hurt’. 

Melanie sets out a holistic view of promoting emotional well-being, so that instead of looking at ‘individual problems’ it is better to look at ‘environments’ and ‘positive capacities’ rather than ‘problems and deficits’. The building of an Intensive Interaction ‘culture’ is seen as being particularly effective where a community can ‘foster productive, pleasant relationships, teamwork [and] mutual responsibility...’. Indeed, she identifies Intensive Interaction as helping create ‘emotionally healthy environments’.

Finally, Melanie argues that Intensive Interaction has a clear place among the other more traditionally identified 'therapeutic approaches' (and therefore it is not solely educational), and also argues (correctly in my view) against those who take a position in which teaching/learning and emotional well-being are seen as separate or discrete issues.

It is well worth a read!

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

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

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

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

We asked ourselves the following questions: 

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

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

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

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

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

1. How might a person’s engagement or task avoidance be presented?

• Having a ‘Melt-down’ e.g. shouting, crying, throwing things, jumping on tables, causing environmental damage, etc.

• Engaging in self-injurious behaviour e.g. hand biting, head slapping, etc.

• Becoming violent e.g. punching, kicking, etc.

• Engaging in inappropriate social behaviour e.g. swearing, abusing others, laughing (at unfunny things), grounding, masturbation, stripping, etc.

• Verbally declining (“no thanks”) or refusing (“No!”) tasks that the person has the ability to do, or has even historically liked doing.

• Ignoring or not responding to requests or the presentation of an activity.

• Closing down a conversation e.g. “its okay luv”, “Not just now” or giving apologies before not doing something.

• Steering a conversation or creating a distraction away from, any given demand.

• Hiding offers of activities e.g. destroying letters, leaflets or invites etc.

• Physically pushing things or people away, out of their immediate space.

• Physical isolation e.g. staying in bed, staying in room, not going out, etc.

• Physical withdrawal e.g. leaving the room, turning their back, etc.

• Social withdrawal i.e. retreating to an ‘inner world’ e.g. shutting eyes, avoiding eye contact, self-soothing.

• Regulating aural and/or visual input e.g. looking away, putting fingers in ears, etc.

• Incongruent verbal and/or non-verbal behaviour i.e. saying something verbally but doing the opposite behaviourally.

• Switching sleep patterns to avoid engagement or contact with others e.g. sleeping during the day, being up at night.

• Using prolonged engagement with technology (or other rigidly focused object orientations or activities) as a shield from external demands.

• Using rigid routines to control the level of potential demand in any given situation.

• Responding negatively to everyday requests (not just potentially novel or potentially ‘challenging’ things); even failing to choose between some offered positive choices.

• Responding negatively to positive comments or praise from others.

2. Why might someone be (or become) engagement or task avoidant?

• Chronic anxiety, including social anxiety and/or prolonged exposure to stress.

• A fear of the unknown, and a wish to avoid uncertainty; a fear of failure, of getting something wrong; a fear of being judged by, or of disappointing others.

• Needing to control a situation (possibly in response to some change or as a means of protection from something) and/or being unwilling to be controlled by others.

• A lack of understanding about what is being asked, leading to anxiety about their ability to complete the given demand.

• Previous or continuing negative experiences leading to trauma.

• A historic lack of positive interactions or feedback in any previous engagements.

• Low confidence or self-esteem and/or a negative self-view or self-worth.

• A lack of the necessary social skills to engage with others.

• A ‘power’ issue, seeking power over those around who historically or currently hold power over the person.

• Due to the onset of puberty and the resultant changes in hormonal levels and/or the menstrual cycle.

• Being in pain or having other medical or health related issues e.g. musculoskeletal, of the bowels, etc.

• Being in a constant state of exhaustion through maintaining a physical posture.

• Being on psychoactive or other medication (e.g. tranquillisers, anti-epileptics), thus reducing cognitive functioning.

• The result of some form of sensory processing disorder or other sensory issue.

• Not being cognitively, emotionally or physiologically ‘ready’ in some way.

• As a means of gaining and holding prolonged attention (even if that is negative attention) from others.

• Boredom with or not being interested in the potential ‘demand’ i.e. not being genuinely demand avoidant.

• Neurodevelopmental issues (incl. P.D.A. diagnosis).

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

• The demands being made are too often too complex or unfamiliar or unpleasant or uninteresting.

• A continued lack of trust in others e.g. due to previous ‘false promises’ e.g. “it’s gonna be okay”.

• A confusing lack of consistency experienced across previous engagements with others.

• Continued experiences of simply not being listened to by others.

• A physical or cognitive deterioration in the person.

• Too much language used, too little processing time.

• Both the person and their carers getting stuck in a negative cycle of perceived and expected failure.

• There being a hierarchical power issue i.e. a battle for control between the person and their carers/staff.

• The use of over-enthusiastic and/or non-genuine initiations or invitations to join in with an engagement.

• Some response from third party reinforcing the behaviour.

• Not addressing a need to alter a current sensory environment.

4. Strategies used within an Intensive Interaction intervention to ameliorate the impact of a person’s engagement or task avoidant avoidance:

• Pausing a lot, and for longer; allowing the person extra processing time.

• Being indirect with requests or invitations e.g. “Bet I can get my coat on before you” will be better than “put your coat on” … or “I’m going now”.

• Being careful when using language e.g. at times more, at times less; using comments and/or statements instead of questions or requests e.g. “you can join me if you want” or “I don’t know where this goes”.

• Sometimes providing reassurance e.g. “we’re all ok”.

• Consider reducing the volume of vocalisations: try whispering!

• Providing ‘failure free’ (i.e. unstructured) tasks or activities, led by the person.

• By staff initiating an activity and allowing the person to just observe, before they then choose to join in (if they want to).

• Reducing the availability of eye contact, if this adds to a perceived level of demand.

• Creating some kind of ‘joint activity’ out of less obvious ‘joint activity’ situations when led by the person.

• Do things alongside or in parallel, but actually not with the person (and sometimes at a distance).

• Presenting the person with ‘Unconditional Positive Regard’ (UPR) irrespective of any level of engagement.

• Being taskless; just seeking ways of equitably ‘being with’ the person.

• Making any necessary adjustments to the sensory or social environment (possibly to tone it down?).

• Being thoughtful about too much, or too little proximity i.e. not being too far away/too close in.

• Being open-minded and genuine, whilst persevering and demonstrating empathy.

• Looking to match the mood and presentation of the person in the current situation… let the person lead.

• Knowing when to stop (i.e. when they’ve had enough), whilst also trying to wind down when things are still going well i.e. ending on a positive.

• When stuck seeking help and/or peer support e.g. by using video analysis for constructive feedback and new ideas.

• Re-labelling ‘avoidance’ to something like ‘engagement and/or task avoidance’ (as in this document) so that we do not get confused with the approaches used with those whose avoidance is diagnosed as ‘Pathological’.

Finally, some potential outcomes of the use of Intensive Interaction with people with engagement and/or task avoidance:

• Improved social engagement with staff or carers.

• Improved relationship development.

• Improved psychological well-being e.g. in mood and self-esteem.

• Improved staff rapport and morale.

• Improved emotional well-being.

• Improved access to educationally enabling activities and engagements, increasing the potential for all future educational and social outcomes.

• Greater independence for the individual.

• A generally improved quality of life!