Preface

Children explore the world using their senses and mobility, driven by curiosity and the feedback from others helps to create awareness of the environment and encourages the communication and interaction process (Zeedyk, 2008). According to Cohen (2001), babies’ communication and interaction process involve a number of non-verbal means, including facial expressions, crying, gurgling, babbling, eye contact, movement and gestures. Communication difficulty may result from learning difficulty, a case where a child poorly learns how to explore the world, how to interpret feedback from others, and how to become aware of what to communicate (Simmons and Watson, 2014). Such children may develop profound and multiple learning disabilities (PMLD.  Jones (2003) argues that children with communication and learning difficulties need responsive and interactive environment that can address their physical, emotional, and mental needs for social and psychological development.

This article then originated from a deep concern for children who have PMLD in Kingdom of Saudi Arabia (KSA), where the PMLD needs are not recognized or addressed by the national educational system, there are very few special schools, that provide educational services programmes for children with multiple disabilities, particularly PMLD children, as most of the special schools are only for moderate intellectually disabled children who have multiple disabilitiesAlquraini, 2010).

 

How PMLD been Define in KSA Practices

The Kingdom of Saudi Arabia defines PMLD as the condition in which a child experiences more than one disability associated with severe learning challenges (Alquraini, 2010). Such disabilities include multiple intellectual disorders, sensory challenges, extreme behavioral disorders, and other forms of disabilities that retard learning. The country recognizes children with PMLD when they demonstrate severe communication difficulties and other medical complications. The Ministry of Education in the KSA also defines PMLD using three categories: First, they are children with severe or mild multiple ability to learn new information or skills from the immediate environment, including the classroom (having impaired intelligence). Second, children with severe or mild ability to adjust to social skills (social impairment), and thirdly, severe or mild disabilities identified before adulthood which cause learning difficulties (Alquraini, 2010).

Different countries define PMLD differently. For instance, America introduces the term “severe” for a child whose IQ is between 20/25 to 35/40 and “moderate” for those whose IQ falls between 35/40 to 50/55 (Emerson and Heslop, 2010).

  Impact of Multiple Disabilities on the child who have PMLD CI ability

Simmons and Watson (2014) observe that some children with PMLD may have an aversion to sensory information because they cannot cope with the greater sensory information around them, affecting their ability to produce sensory-motor skills, coordinate their body movement and accept sensory input, reducing the child’s motivation to learn from the environment.

Imray (2008) further demonstrates that children with PMLD sometimes fail to develop good body posture required in different contexts like classrooms. They may often lie down in inappropriate positions, which affect their sitting, inflexible body movements, and poor posture positions. All these physical developments are essential for their involvement and participation in all aspects of everyday life. According to Corke (2012) children with PMLD find it difficult to maintain a good postural position and also find it challenging to control body movement when they are participating in social activities, as any movement necessitates a fine adjustment of posture and balance.

Moreover, Corke (2012) reports that an imperfection in the muscle controls of lips and tongue will limit or prevent the child’s ability to speak or make some intelligible sounds. Lastly, their physical impairment usually requires some surgeries to be performed on these children, meaning that they spend the majority of their time lying on their back in hospital or at home (Bellamy, et al. 2010).

Dutton and Bax (2010) further demonstrates that learning difficulties can also  result from medical causes; for example, ear infections may lead to head banging; the side effects of some drugs or a sensory impairment may cue visual-oriented mannerisms, such as eye-poking and hand movement in front of the child’s eyes.

Communication ability for children who have PMLD

Bellamy, et al. (2010) stated that communication is a purposeful response that the child makes with an expectation of affecting the behavior of another person.

 

Ware (2003) noted that PMLD children’s CI is in a very early pre-intentional stage of development, which typically occurs in Piaget’s Sensory motor stages from birth to 24 months. Doherty and Hughes (2009) identify these stages; in the ‘reflexive stage’, the child produces different vocal sounds relating to hunger or comfort before they actually begin to formulate coherent speech. If the adult’s responses are consistent, the child realizes that he/she can achieve a given goal through repeating the sound or expression that elicited that response. At this point, via several reflex actions made by the child and the consequences they produce, the child can learn about himself/herself and his/her environment, and how things happen through movements and sensations; the child moves to the ‘reactive stage’. In the ‘proactive stage’, he/she is more capable of conveying different clear and deliberate signs of communication, producing intentional communication perceptible by others.

Theoretical Background of Intensive Interaction

Developmental literatures and other surveys have influenced Intensive Interaction approach to handling people with PMLD. Psychological theories of ‘augmented mothering’ demonstrate that infants start interacting with adults immediately after birth. Within one year, children attain fundamentals of communications which help them to give adequate sustained attention and take part in social interactions (Smith et al., 2003). Children then learn to respond to and communicate through facial expression and eye contact, all which take place through interaction (Emerson and Heslop, 2010).

According to Nind’s (1996) interaction between two people can only take place when they all have the mastery of communication fundamentals. It is these fundamentals that help children to learn how to initiate and sustain communication. A survey by Nind and Hewett (1994) demonstrated that the fundamentals of communication are helpful for building social interactivity. People learn how to communicate when they develop the desire to be with others.

These theoretical standpoints motivated the design of the Intensive Interaction (II)   approach to teach people with PMLD how to communicate. II is an exciting learner-centered technique for teaching communication skills to children with PMLD. Care staff, teachers and speech instructors can use the technique to help children.  It helps them to develop interest in looking, smiling, and vocalizing.

Intensive Interaction in Research Practices

            Nind (1996) demonstrates that psychological needs of people with PMLD have been neglected, yet by use of intensive interaction, their difficulties can considerably be solved. Teachers have traditionally used Intensive Interaction with children with PMLD or autism. In 2008 at an Intensive Interaction conference researchers recommended its use with clients or children with profound communication difficulties. The conference also approved the use of II with individuals with, brain injury, sensory difficulties, dementia, and even stroke.

A team of research psychologist at Dundee University recommends the use II with clients with communication difficulties worldwide. The team reports that II is effective for positive outcomes, with clients attaining fundamentals of communication when the approach is used regularly (Zeedyk, 2008).

Zeedyk (2008) proposed the use of micro-analytic technique to closely record and analyze videotapes on the timing of the frequency of occurrence of a given behavior. The analysis gives insights in to how II influences the attention of the clients and how they try to sustain the interaction.

Dr Peter Coia (2008), a clinical psychologist, proposes a neural mechanism that attempts to explain how II induce communication responses.  Dr Peter Coia argues that a mirror neuron initiates responses when an animal acts and when the animal sees another animal perform the same action. Human brain is also consistent with the behavior of mirror neuron in the pre-motor cortex (Iacoboni et al., 1999). The mirror neuron can help in vocal imitation, helping clients to recognized thei own behavior when mirrored by others (Coia, 2008). The approach is interesting as most of its features are now well understood by psychologists and instructors.

How to do Intensive interaction with PMLD

People with communication and learning difficulties ultimately develop their own ways of communicating to self. Their body and brain communicate. Pawlyn and Carnaby (2009) argue that to do Intensive Interaction with them requires getting in to their communication and making it not only intra-personal, but also interpersonal. Psychologists argue that such people, instead of exploring and interpreting the external environment, their brains are self-exploring in a repetitive loop, which culminates in to a personal language. Intensive Interaction should seek; therefore, to observe and stimulate significant behavior that is significant for them and which they can understand (Corke, 2012). This is why II is individual-centered. The approach is to help people with PMLD to generate interactive behavior.

Proponents of the Intensive Interaction propose the use of the approach at any time and in any place to seize every opportunity as it arises.  First, it can be applied during care tasks, free time, and when clients tend to be social. Second, instructors can secure time for the activity every day for quality interaction (Nind and Hewett, 1994). The following activities can help in actualizing II with clients with PMLD.

First, start with making an observation. This involves identifying the development of an ongoing form of what the person with PMLD is doing during the conversation at that instant. The observation should be sensitive to make appropriate judgment on the development of the interaction and make flexible responses where possible (Coia, 2008).  The implication is that the approach may not require a list of activities to undertake. It is about interacting with them to let them explore the environment from without. Repossesses are expected to be contingent to their initiatives and to how they come up with those initiatives. The success of the process depends on observing and understanding how clients make those initiatives in order to effectively stimulate their effective state. According to Caldwell (2008), whoever is guiding in the conversation should not expect a particular behavioral response, but rather, to “be with” the person as they are during the conversation. More observations are made on their gestures, rhythms, and vocals so that every response made is of meaning to them.

For every feedback, immediate response is advised to help them sustain the conversation positively and enjoyably.  According to Coia (2008), observation should involve other colleagues videotaping the interaction where possible. In this way, it is possible to evaluate oneself for better improvements.

The second issue that will warrant attention is the need to listen, or to get information with all senses. It is the only way to get the movements, gestures at an instant. The goal is to pull them out of their lonely inner world on the world outside to make their sensory monologue turn in to a dialogue as well as interactional exchange, with the outside environment. Some of the people with PMLD pay attention little issues like small clicks and even their own breathing. All these should be taken in to considerations.

The third issue is to mainly let them lead ones they are pulled out of their inner world.  Jones (2003) argues that II is effective when one responds to the behavior of the client and what they do. This involves giving appropriate comments and sometimes imitating them playfully. Caldwell (2008) further mentions that responding to their initiated behavior and not leading in the conversation ensures that no demand is made out of them. It also allows the best chance to start exploring their external world. The topic of conversation should also be of their interest.

The fourth issue is to consider everything the person does as a form of communication. Hewett (1995) argues that the instructor should always discern the social meaning in every behavior of the client, even if the mean may not be clear. The motivation behind this consideration is that the client gets to feel what it is to communicate and get response from someone. The instructor can make more and appropriate movement to show the interest in the conversation. Amid all these considerations, the conversation should have fun and free to take any direction and any topic.

Using Intensive Interaction on a Child with Cerebral Palsy and other Learning Difficulties

Abubakr suffers from cerebral palsy and experiences severe learning difficulty. The information about him is that he likes sitting at the corner of the class when others are learning with his head down, staring at a fixed point on the floor for as long time he can take to be there.  When the teacher tries to get his attention, he gets so indifferent and demonstrates disinterest in any kind of engagement. Earlier attempts by physiotherapists to save the situation and to help him sit in an upright position have yielded little fruits for the last two years. The parents are currently worried that the posture may further lead to spinal complications. The boy like making some sort of rhythmic sound while sucking his saliva.

Abubakr’s case is both interesting and complicated as any other issue to do with disabilities. However, it can sometimes get simpler when Intensive Interaction is involved. The first step to getting the solution is to make the slightest observation about the boy. The communicator should first learn the fact that the boy looks down, not ready for engagement, and likes sucking his saliva. The fact that the sucking of the saliva is rhythmic, the communicator can start by answering the sound. Making the same sound will present external stimulus that is not from within Abubakr. If he responds to the answer, then it may become the key to the door of thoughts and feelings of Abubakr. The next step is to encourage the boy to do other rhythmic sounds, maybe by tapping something above his head. If he tends to get interest in music then the better for keeping him busy. Even if other attempts to engage the boy may fail, it will be still the best starting point since he shall have developed an expectation from the world outside himself.

 

 

References

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