Intensive Interaction: Using Body Language to Communicate Abstract

Volume 19, Number 1, 2013

Correspondence

Keywords

intensive interaction,

autism,

intellectual disabilities;

emotional engagement,

challenging behaviours

phoebe@caldwell237.

orangehome.co.uk

Author

Phoebe Caldwell

The Norah Fry

Research Centre,

University of Bristol,

School for Policy Studies,

Clifton, Bristol, UK

Intensive Interaction: Using Body

Language to Communicate

Abstract

Intensive Interaction is an approach that uses body language

to facilitate positive engagement with non-verbal or semi

verbal children and adults with intellectual disabilities and or

autism and with whom communication is often difficult. Posi-

tive outcomes include a deepening of emotional engagement as

measured by increases in eye contact and social responsiveness

and a reduction in distress (challenging) behaviours.

[Note: Intensive Interaction is being used all over the world in

groups of individuals. It is strong in Australia (Barber, 2008)

and also used in Scandinavia and Europe. It has been taught

in Bulgaria and other Eastern European countries, and used

by people as far widespread as Tasmania and Saint Helena.

In the UK it is used by schools, the National Health System,

social services, private providers, therapists and families.

Intensive Interaction is a communication approach that is

not generally familiar to those in the field of intellectual

and developmental disabilities in the United States, where

interventions tend to be behavioural and medical in nature.

Because this approach is a key tool in two other articles in

this special issue on innovative approaches, and has recently

been introduced in Ontario, it is important that it be intro-

duced to Journal readers. This present article by Dr. Caldwell

is an edited version of a related article first published in 2011

by www.intellectualdisability.info, a Health Alert initiative

jointly managed by the Down’s Syndrome Association and

St. George’s, University of London (SGUL). This adaptation

of the original article is published with permission from the

editors of this website initiative.]

This article introduces an approach called Intensive Interaction

that allows us to engage with children and adults with intel-

lectual disabilities with whom we find it hard to get in touch.

They in turn find it hard to communicate and are often dis-

tressed. Many are on the autism spectrum. This review dis-

cusses using body language to align ourselves with the affec-

tive state of our communication partners and the part played

in this by the mirror neuron system. It questions the idea that

autism is a problem of motor neuron deficit. As illustrated

in the article, persons with autism are able to copy if their

stress level can be reduced and our initiatives and responses

are already part of their repertoire. Sometimes if they are

particularly relaxed they will also copy actions that are not

part of their normal repertoire.

Developmental Disabilities

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caldwell

Communication

We communicate in two different ways. Most

of what we are consciously aware can be called

functional communication, informing each other

of our needs, on the level of “Do you want a cup

of tea?,” or sharing more sophisticated informa-

tion. In people with intellectual disabilities or

autism who are non-verbal, functional commu-

nication may be assisted by sign systems such

as Makaton (Grove & Walker, 1990) or PECS

(Picture Exchange Communication System)

(Bondy & Frost, 2001). What we are all less aware

of, is how we inform and monitor each other’s

emotional states all the time. This emotional

engagement is expressed through our body lan-

guage, not so much by what we say or do, as

how we do or say it. For example, in people who

are non-verbal, there is a difference in the affec-

tive state of someone who is flapping their hand

gently and one who is thrashing the air with it:

the same gesture, but in the first instance we

know they are relatively calm and in the latter

that they are expressing severe distress.

The paradigm underlying Intensive Interaction is

that of the infant-mother interaction: the infant

initiates a sound or movement or rhythm and

the mother responds in an imitative way. Once

the baby’s initiative is sufficiently confirmed,

the infant is able to move on and try out some-

thing else. It is crucial to emphasise that in using

Intensive Interaction we are not in any way

infantilising our conversation partners. For all of

us, this non-verbal dialogue is a primary com-

munication pathway, laid down in babyhood but

remaining with us all our lives. Based on imita-

tion, it has recently become clearer why Intensive

Interaction is so successful in attracting the atten-

tion of a conversation partner. Much research

is now devoted to the mirror neuron system, a

network of nerve cells in the brain that recog-

nises actions made by other people and fires

off a sensory motor response (Hamilton, 2013;

Hamilton, Brindley, & Frith, 2007; Molenberghs,

Cunnington, & Mattingley, 2009; Rizzolatti,

Fabbri-Destro, & Cattaneo, 2009; Rizzolatti,

Fadiga, Gallese, & Fogassi, 1996; Rizzolatti,

Fabbri-Destro, & Cattaneo, 2009). Seeing another

person yawning triggers a tickling sensation in

one’s own jaw, even if not an outright yawn. It is

speculated that this mechanism can also apply to

emotions: it is easy to feel dragged down in the

company of someone who is depressed.

Intensive Interaction

People who are unable to communicate develop

ways of interacting with themselves in such a

way that brain and body engage in an internal

conversation through self-confirmation. Each

individual develops their own personal lan-

guage of stimuli that have significance for them

and to which they “listen.” The first question

we have to ask ourselves is, “How is this person

talking to themselves?”

We start with “observation” but need to think

of observation as the development of an ongo-

ing picture of what our conversation partner

is doing now, this minute. We are looking for

the feedback they are giving themselves so

that we can join in and build up a conversa-

tion using their body language as a basis. We

need to avoid the pitfall of drawing up a list

of activities we “do” with them: our responses

need to be contingent, not only to their initia-

tive but also, how this initiative is made, since

it is this that will allow us to tune into their

affective state. We have to empty ourselves of

any behavioural expectations and learn to “be

with” this person as they are at present, using

their initiatives to respond in ways that have

meaning for them.

We need to approach our interaction in terms

of a “listening” with all our senses, tuning in

to any minute movements, gestures or sounds,

focusing on what this person is doing at this

particular moment. This will be our way in to

our partner’s inner language, our aim being to

draw their attention from their solitary inner

world onto ourselves in the world outside, so

that their sensory monologue becomes a dia-

logue, an interactional conversation that we

can now share. At the same time we need to be

aware that a person’s attention may be focused

on as little as their own breathing rhythm, an

activity we overlook since it does not have sig-

nificance for us.

Below are two case studies which document the

successful application of Intensive Interaction.

Case studies descriptions provided are of indi-

viduals in the authors’ practices. Permission

to publish the studies has been obtained from

these persons and/or their families. Pranve’s

name is his real one, others have been changed.

v.19 n.1

Intensive Interaction

Case Study 1: Debbie

Debbie, has cerebral palsy and severe intellectual

disability. She sits in the day centre with her head

down, staring at the floor, apparently uninterested

in any form of activity. The physiotherapist has been

trying for two years to get her to sit upright since

her current posture is likely to cause her spinal prob-

lems. When I listen carefully she is making small

but regular sounds sucking her saliva. We begin to

answer her minute sounds. Within a few minutes

Debbie’s head has come up and she is looking from

one of us to another for responses and smiling. Her

supporters continue to interact with her as demon-

strated. Within three weeks she sits with her head up

on a regular basis, looking around her to see what is

happening. The world outside her has become suffi-

ciently meaningful to have drawn her attention from

her inner world onto her surroundings

This simple interaction not only claims Debbie’s

attention (she raises her head) but also encourages her

to engage with us, in the sense that she refers back to

us, deliberately making a sound and waiting for our

response. No longer self-confirming, she has devel-

oped an expectancy from the world outside herself.

Using Intensive Interaction, we are not just imitat-

ing or mimicking, even though this is where we may

start. But in order to move from attention to engage-

ment, we need to be aware of our partner’s entire

body language: so we may answer a sound with a

relevant touch or vice versa but always keeping with-

in their repertoire. Sometimes, the way that people

without speech express how they feel is complex.

Case Study 2: Pranve

Pranve is on the autistic spectrum and hyper-

sensitive to sound. He attacks people to the

point where it has become difficult to find care

staff who will support him. I am warned when

I arrive he will probably either attack me or run

away.

He lives on the edge of an airport and is distressed by

high frequency engine whines lifting his head and roll-

ing his eyes towards the sound. When he is anxious,

he touches the fringe of the lampshade beside his chair

and runs his hand down the stand. When he is angry

he will sit in the hall banging the door with his fist.

Pranve self-confirms by rubbing his fingers; he

carries a ball of strings underneath his armpit and

spends time sorting them.

Pranve makes sounds, a particular rhythm, “er-er-

er,” which turns out to be a pre-verbal version of

“Where’s Charlene?,” his sister who no longer lives

with the family. This is the only thing he has ever

been known to say.

When I arrive, I take care not to invade his personal

space before making contact with him. So when his

mother opens the door I listen ? and from another

room hear, “er-er-er,” I respond, “er-er, er-er-er?,”

with a lift at the end, rather in the way one might

say, “Hello, how are you?” He comes straight out

and takes my hand and leads me to the sitting room.

I ask him if I may sit down and he responds by point-

ing to the chair.

I sit beside him and respond to each of his small

sounds, tuning into how they make me feel, but alter-

ing the rhythm or pitch occasionally. I am answering

rather than copying. At first he is half-turned away

from me but he gives me his hand which I shake in

time to the sounds we are exchanging. He becomes

more interested and turns round to face me, laugh-

ing. He introduces new sounds and movements to

which I respond. We are soon engaged in a complex

non-verbal interactive conversation.

I draw the shape of his different sounds on his fore-

arm and he leans forward and looks with interest,

then tries a different sound to which I respond with

a shape that reflects its rhythm and pitch.

At one stage I become over-confident and move in

when he is not looking. Immediately Pranve thumps

my arm, but quite gently. He is telling me that he can-

not cope if something happens unexpectedly. Now he is

anxious he goes into his lamp stand routine, a feature

of his language that I do not fully understand until I

revisit our interaction on video. He wants me to con-

firm this sequence of touching the fringe and running

a hand down the stand and tries to guide my hand

to meet his need. He is clearly disappointed when I

miss this. However we are able to return to using his

sounds to interact. Eventually our session comes to an

end when I fail again to pick up on his anxiety routine.

He pushes me away gently and we have a break. Then

he goes into the hall and bangs the door. I respond by

banging my feet on the floor. He laughs and throws his

ball of string into the sitting room, a strategy which

means he has to come back to us to retrieve it. He

comes in, spots his mother and goes over and hugs her.

He drags a spring-backed chair over in front of me

and bounces on it, turning round to me inviting me to

bounce him. I do this every time he makes a sound. He

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caldwell

begins to hum four notes, as it turns out, the first line

of the nursery rhyme, “Baa Baa Black Sheep.” After

trial and error he gets the words and then goes on to

produce the tune and rhythm of the second line, his

face and jaw working for some considerable time before

he can make the necessary muscular movements. As

he places his head at different angles one can see the

meaning of the phrase “getting one’s head round some-

thing.” His jaw wobbles with the effort but eventually

he sings these two lines confidently. His family and the

speech therapist who is present are astonished: while

he must have heard this song when he was younger,

to their knowledge he has never before said anything

before except the phrase, “where’s Charlene?”

During the three hours I am with Pranve, apart

from the one time that I startle him, he shows

no aggressive intent and is clearly delighted

with our interactions. But also, after about

twenty minutes, he is no longer reacting to the

scream of the planes passing over the house, so

close their wheels are down for landing. His

interest in our conversation is overriding his

hypersensitivity to the high frequency whines

of the jet engines (Caldwell, 2006).

I have presented this intervention in detail

because it illustrates some of the interwoven

subtleties of a body language interaction. I am

not just working with repetitive behaviour but

more with what might be thought of as the

total ecosystem of a person’s life and how they

interact with their surroundings.

When using their body language, people with

autism start to engage. They relax, their whole

demeanour and posture change. Eye contact

increases, they start to look round, they can

generalise and copy and are interested in their

conversation partner in a way that is not gen-

erally accepted to be typical of people on the

autistic spectrum (Zeedyk, Caldwell, &Griffiths

(2009). And contrary to the idea that people on

the spectrum have a deficit in their mirror neu-

ron system (Ramachandran, 2011) which might

account for their communication difficulties

they have, they always recognise and respond

to gestures and sounds, provided they are

already part of their significant repertoire.

Intensive Interaction can be applied across a

wide field of disability. For example, Hart uses

Intensive Interaction to work with people who

are deaf-blind (Hart, 2008). He highlights the

need for care staff to learn the capacity to “feel”

the world from a tactile perspective, develop-

ing “communicative landscapes” to capture the

attention of their deaf-blind partner in order to

negotiate joint activities.

Each time we use Intensive Interaction we are

beginners, in that we have to learn the signifi-

cant language for a specific individual from

our conversation partner. Inevitably there will

be some trial and error: our partner will latch

on more quickly to our using certain aspects of

their language than others. For example, David

who is biting pieces of jigsaw may be unmoved

when we try replicating his activity, since the

feedback he is giving himself is that of pressure

in the area of the mouth rather than visual. In

this case he responds very quickly to the appli-

cation of vibration in this area (Caldwell, 2009).

Intensive Interaction is particularly effective

with people on the autistic spectrum who are

struggling with a sensory environment that is

behaving like a kaleidoscope, where the pat-

tern never settles. This instability can appear as

life-threatening: responding in terms that are

meaningful to the brain confirms what the per-

son is doing. Donna Williams, who was diag-

nosed with autism as an adult, says that it is

like having a life belt thrown to her in a stormy

sea (Williams & Magnus, 1993).

When engaging with people with behavioural

distress, we need to ask two questions. The

first asks, “What do I do now when I am being

attacked, or my partner is self-harming?” The

second is, “Why does he or she feel the need

to do these things?” So when I use Intensive

Interaction, it is as part of a dual approach: I

am looking to reduce the triggers to sensory

distress such as the sensory hyper- and hypo-

sensitivities, emotional overload and the diffi-

culties caused by failure to process speech. On

the other hand, I am looking to increase signals

that the brain can process easily, such as use of

body language combined with strong proprio-

ceptive input.

Using Intensive Interaction to

Construct an Autism-Friendly

Environment

People with autism live in a sensory maelstrom

(Ramachandran, 2011). It is difficult for them to

v.19 n.1

Intensive Interaction

know what they are doing. Pranve is confirm-

ing himself by activities that are hard-wired-in

elements of his body language such as hand

movements and string sorting, which help him

construct a landscape that has meaning for

him. In the dual autobiography written by Judy

Barron, we learn that when Sean repetitively

switched the lights on and off it gave him a

wonderful sense of security since it was exactly

the same each time. In an unpredictable world

he knew what was going to happen (Barron &

Barron, 1992).

One of the reasons Pranve attacks people is

because something has happened that he has

not foreseen. He becomes sensorily overloaded

and his autonomic nervous system tips him

into an “autonomic storm” (Ramachandran &

Oberman, 2006), an experience that is both con-

fusing and can be extremely painful. As Pranve

becomes more relaxed his brain finds it easier

to organise his muscular responses and he says

clearly, “Where’s Charlene?” instead of mutter-

ing the rhythm and then goes on to astonish

his family and speech therapist by singing a

nursery rhyme.

Over the next two months, Pranve’s parents use

his body language to communicate with him.

His behaviour calms and he is able to return on

a part-time basis to the day centre from which

he had been excluded. His mother says he has

the odd off-day but on the whole they can now

interact with him and manage his behaviour.

A teacher using Intensive Interaction with her

students sums up the effects. “They want to be

with people now.” Wanting to be with other

people, desiring relationship is what I hope to

achieve for my conversation partners.

How Well Does Intensive

Interaction Work?

Intensive Interaction is not a “cure” for autism,

in the sense that if we discontinue using their

body language to engage with them, their dis-

tressed behaviour will return. We have to use it

as a continuing way of communication explor-

ing, and building on the emotional engagement

and relationship it fosters. When the brain is no

longer under processing pressure it begins to

work more effectively on its own account, with-

in the limitations of its intellectual disability if

this is present. This is especially true for people

with autism who are so vulnerable to environ-

mental stress.

Success is dependent on maintenance. Since

Intensive Interaction holds our partner’s atten-

tion, we can sometimes use it to guide them

through activities they would otherwise find

threatening by constantly supplying sounds

or movements or gestures that are part of their

repertoire. These act as landmarks that the

brain can focus on and exclude the avalanche

of stimuli that threaten to overwhelm them.

While there are a massive number of anecdotal

studies from practitioners all round the world

as to the effectiveness of Intensive Interaction

there is rather less empirical evidence.

However, in spite of the difficulties presented

by standardisation, Zeedyk, Caldwell, and

Davies (2009) have analysed filmed Intensive

Interaction interventions frame by frame and

shown that, although the time-line may vary,

there is always a significant increase in eye con-

tact, in social responsiveness and an increase

in the desire for proximity. Nind and Kellett

(2002) show a significant decrease in disturbed

behaviour in adults with learning disabilities

when their support staff engage with them

through corresponding actions. In a survey

commissioned by Mencap and the Department

of Health, UK, on communication with peo-

ple with profound and multiple disabilities,

Goldbart and Caton (2010) find that Intensive

Interaction is one of the approaches most wide-

ly used. Over 85% of speech therapists in the

survey were using it.

Fundamentally, Intensive Interaction is

straightforward. Laying aside our own agen-

das, we start by looking and listening to what

our conversation partners are doing, the physi-

cal feedback they are giving themselves and

how they are doing it – at the same time, tun-

ing in to how they feel, using our own body

language to respond and building up non-ver-

bal conversations and emotional engagement.

Key Messages From This Article

People with disabilities: “Just because I cannot

speak it does not mean I have nothing to say.”

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caldwell

“Talking to me through my body language is

like having a delicious conversation.” “I like it

when people tune in to me.”

Professionals: Intensive Interaction facilitates

getting in touch with people with intellectual

disabilities/autism in a way that is accessible

and meaningful to them, by engaging them

through their personal repertoire including

their body language.

Policymakers: Genuine communication with

people with intellectual disabilities should

inform all policy decisions relating to their sup-

port and empowerment.

Acknowledgements

Thanks to Marika Korossy for her generous

assistance with preparation of this manuscript.

For correspondence and information about

Intensive Interaction and training courses,

please contact:

Phoebe Caldwell, DSC Hon.

Honorary Fellow,

The Norah Fry Research Centre

University of Bristol

School for Policy Studies

8 Priory Road,

Clifton, Bristol, BS8 1TX, UK

phoebe@caldwell237.orangehome.co.uk

References

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here. New York, NY: Simon & Schuster.

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and autism: Promoting Autism FaVourable

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Developmental Disabilities, 19(1): 8–23.

Caldwell, P. (2006). Finding you finding me:

Using intensive interaction to get in touch

with people whose severe learning disabilities

are combined with autistic spectrum disorder.

London, UK: Jessica Kingsley.

Caldwell, P. (2009). Training Film: Autism and

intensive interaction: Using body language

to get in touch with children on the autistic

spectrum. London, UK: Jessica Kingsley.

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and people with the most complex needs: What

works and why this is essential. London,

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of a deficit in the motor neuron system?

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doi:10.1076/j.neuropsychologia.2006.11.022

Hart, P. (2008). Sharing communicative

landscapes with congenitally deaf blind

people: It’s a walk in the park! In M. S.

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individuals with communicative impairments:

Making contact (pp. 66–83). London, UK:

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More Resources

Intensive Interaction Training Courses

There is a problem with training, in that being

highly intuitive, laying down rules tends to

box it in an unhelpful way. The best training

inspires people so that they go away and try

it. Since it normally works first time, trainees

usually want to go on with it. Some will need

long-term support. In the UK, training is pro-

vided by the author. More formal courses are

run through the Intensive Interaction Institute

based in Leeds by Dave Hewett. Others who

run courses include: Cath Irvine (cath@inten-

siveinteraction.co.uk); Pete Coia at Fieldhead

Hospital, Wakefield; and Helen Beltran, speech

therapist in Glasgow.

While there is no formal training as yet in

Ontario/Canada, there is now a serious interest

in Toronto and several clients with intellectual

disabilities are being supported in this way.

Intensive Interaction Training Films

Caldwell, P. (2002). Learning the language [DVD].

Brighton, UK: Pavilion Press.

(Follows a three-day intervention using

Intensive Interaction to get in touch with

a young man with very severe autism,

using his body language, followed by

discussions with Care Staff)

Caldwell, P. (2004). Creative conversations

[DVD]. Brighton, UK: Pavilion Press.

(Intensive Interaction being used with

people with multiple disabilities, mainly

severe cerebral palsy)

Caldwell, P. (2007). Reaching Ricky [Teachers

TV made by Available Light Productions

Ltd., Bristol, UK]. Retrieved from http://

www.tes.co.uk/teaching-resource/

Reaching-Ricky-6084099/

(Working with a child with autism in

school)

Caldwell, P. (2009). Autism and intensive

interaction: Using body language to get in

touch with children on the autistic spectrum

[DVD]. London, UK: Jessica Kingsley.

(This three-part film includes a twenty

minute uncut Intensive Interaction

intervention with an eight-year old child,

whom staff cannot make contact with and

whom Caldwell has never met before. The

film moves from initial rejection to total

attention.)

Clips from these films and other interventions

with children aged 3–18 may be viewed at

http://www.phoebecaldwell.co.uk/films.html

Radio Interview

Ledgard, C. (producer). (2013, January 15).

[Interview with Michael Rosen]. Word of

mouth, autism and learning difficulties. [Radio

broadcast]. Bristol, UK: BBC Radio 4.

Retrieved from http://www.bbc.co.uk/

programmes/b01pty43

(In this interview, Phoebe Caldwell

talks about the principles of “Intensive

Interaction,” and why listening and non

verbal communication are central to her

work. Parents, researchers and carers

also discuss with the host the ways we

communicate with people with autism or

profound learning disabilities.)