Intensive Interaction at the High Hopes Pediatric Centre in Dubai

I know that this a is a bit late in coming (sorry about that Lynne, Aida and the therapy team; I've been a bit busy), but I would just like to acknowledge the very warm welcome I had at the High Hopes Pediatric Therapy Centre in Dubai at the end of 2019. 

So Dubai can now be added to the long list of countries (or states ... or emirates?) where Intensive Interaction is now practiced! Surely we must be nearing a critical mass where we should get some acknowledgment at the United Nations General Assembly (we really should ... and I don't mean that as a joke!).

I was invited to Dubai by Lynne Jafar (founder of High Hopes and mum to Lulu) who I met at the 2019 CDKL5 family conference in Edinburgh (see my Blog of 05/07/19). Attending one of my workshops at this CDKL5 conference, Lynne immediately saw the value and power of Intensive Interaction, particularly so for her daughter Lulu. So I was invited to introduce the approach to her multinational therapy team at High Hopes (Hi to Viviane, Emma, Kunali, Priscilla, Jonathan, and Lindsey - pictured below). 

We spent a very productive 4 days together, and I had the great pleasure of meeting and interacting with a number of the children who regularly attend High Hopes; often with their parents also in attendance. So I was able to talk about the approach, and the kinds of social communication and developmental outcomes that we would expect to see through the sustained use of Intensive Interaction. I also got to give open 'Q & A' type sessions for both parents and other Dubai based professionals; with about 12 from each group attending who were keenly interested to hear more about Intensive Interaction. 

 

So thanks again to Lynne and Aida (pictured above on the right). It always takes someone to be the enthusiastic and dynamic 'change agent'; the person who is the first to introduce Intensive Interaction to a new place, a new service, or even a new country. I feel that High Hopes can be just that ... it can act as a positive catalyst for the future development of Intensive Interaction across Dubai. It can genuinely bring 'high hopes' to many other parents and family members in Dubai to interactively attune and connect with their children with special needs ... so many thanks and congratulations for starting that process.

Oh, and the Dubai weather was fantastic (almost as warm as the welcome), and the local architecture was out of this world (almost literally). 

Non-medical interventions for individuals with Rett syndrome: A systematic review

For my Blog this week I am reporting on a review I recently read on the use of 'non-medical interventions' with girls with Rett syndrome (or RTT); a rare neuro-developmental disorder occurring in about one in every 10,000 girls. Perhaps unsurprisingly it is titled:

'Non-medical interventions for individuals with Rett syndrome: A systematic review' by Annika Amoako & Dougal Hare (Nov, 2019) Journal of Applied Research in Intellectual Disabilities, DOI: 10.1111/jar.12694.

From the abstract: research into Rett syndrome was identified as including various medical interventions, but non-medical interventions were found to be 'relatively under-researched' (no surprises there then!). The authors of this paper therefore conducted a systematic search for peer-reviewed papers investigating the use of any such non-medical interventions for girls with Rett syndrome. 

13 studies were reviewed and the interventions were generally described as being primarily 'communication interventions' with these interventions including: 'music, assistive technology, augmentative and alternative communication strategies, attentional training and cognitive rehabilitation training'. 

The findings of the paper were that: 'all studies reported positive outcomes across communication, quality of life, brain stem activity, physical fitness and a reduction in stereotyped behaviour'. However the review highlighted a 'paucity of high-quality research'  in this non-medical area. 

... but interestingly, the paper finishes with this final, highly referenced paragraph:

'The early focus on parental involvement in interventions has diminished over the years, with increased focus on utilizing recent advanced software. Given most children reside in the family home, a broader research focus is required to incorporate the impact of family and interaction interventions as opposed to solely software-led assistive technology. Future research should investigate interventions that have been researched within the remit of intellectual disabilities to investigate its utility in the RTT population. For example, there is a growing evidence base of the use of Intensive Interaction in individuals with severe and profound intellectual disabilities. Research has reported on improved pre-verbal communication skills, maintenance of social engagement and relationships after an Intensive Interaction intervention (Anderson, 2006; Argyropoulou & Papoudi, 2012; Firth, Elford, Leeming, & Crabbe, 2008; Kellett, 2000, 2005; Samuel, Nind, Volans, & Scriven, 2008; Watson & Knight, 1991; Zeedyk, Caldwell, & Davies, 2009; Zeedyk, Davies, Parry, & Caldwell, 2009).'

And of course, I agree. I am not saying that 'software-led assistive technology' will not have an important part to play in helping such children, but given that most children do 'reside in the family home' surely any improvement in 'pre-verbal communication skills, maintenance of social engagement and relationships' is vitally and profoundly important in developing improved 'quality of life', for the children with Rett syndrome, and also their families as well! 

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).