Enhancing sustained interaction between children with congenital deaf-blindness and their educators.
Disabled children (Social aspects)
Interpersonal relations in children (Research)
Educators (Powers and duties)
Janssen, Marleen J.
Riksen-Walraven, J. Marianne
Van Dijk, Jan P.M.
Ruijssenaars, Wied A.J.J.M.
|Publication:||Name: Journal of Visual Impairment & Blindness Publisher: American Foundation for the Blind Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Foundation for the Blind ISSN: 0145-482X|
|Issue:||Date: March, 2012 Source Volume: 106 Source Issue: 3|
|Topic:||Event Code: 290 Public affairs; 310 Science & research|
|Geographic:||Geographic Scope: Netherlands Geographic Code: 4EUNE Netherlands|
Educators and children with congenital deaf-blindness experience
major challenges in building interactions that are reciprocated and
sustained (Chen, Klein, & Haney, 2007; Vervloed, Van Dijk, Knoors,
& Van Dijk, 2006). Interaction is defined as the process of two
individuals mutually influencing each other's behavior (Janssen,
Riksen-Walraven, & Van Dijk, 2003b).
Sustained interaction is defined here as interaction with a reciprocal three-turn structure (Levinson, 1983; Linell, 2009): One of the interaction partners takes an initiative; the other reacts with a confirmation, an answer, or a new initiative; and then the first reacts again. The absence of breakdowns is important for good interaction and is a basis for high-quality communication in which intentions and meanings are expressed (Reddy, 2008; Rodbroe & Souriau, 1999).
Earlier studies have shown that affect attunement and sensitive responsiveness are crucial for a child to feel recognized and for synchronizing early conversations (Janssen et al., 2003b; Stem, 1985-1998; Trevarthen & Aitken, 2001). We previously presented the Diagnostic Intervention Model (DIM) as a guide for designing and implementing interventions to foster harmonious interactions (Janssen et al., 2003a) and examined the efficacy of the DIM in the Contact effect study (Janssen et al., 2003b). Considerable effects were found on core interaction categories for both the educators and the children (see Janssen et al., 2003a; Janssen, Riksen-Walraven, Van Dijk, Ruijssenaars, & Vlaskamp, 2007; Janssen, Riksen-Walraven, Van Dijk, & Ruijssenaars, 2010). However, the dyadic category of sustained interaction was not evaluated.
The study presented here demonstrated the effects of the DIM on sustained interaction within a reciprocal three-turn structure (such as the educator-child-educator or the child-educator-child). We reanalyzed observational data from the Contact effect study (Janssen et al., 2003a) and looked at the duration of sustained interaction, the duration of the longest interaction sequence, and the mean number of turns in a sequence. The results are evaluated and discussed here.
The study followed the tenets of the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was approved by the Institutional Review Board of Royal Kentalis in the Netherlands. Informed consent was obtained from the parents and educators.
The study included six children and adolescents with congenital deaf-blindness: Rolf and Ruud (both aged 3), Sam (aged 5), Kris (aged 10), Nicole (aged 16), and Anton (aged 19), referred to here as "the children." The children were selected using three criteria: dual sensory impairments since birth; a limited expressive vocabulary; and the requests of their parents, teachers, or caregivers for interaction coaching. Rolf is visually and hearing impaired (as a result of Cornelia de Lange syndrome) and uses the visual, auditory, and tactile modalities in communication. Ruud is blind and hearing impaired (as a result of Leber's congenital amaurosis) and uses the auditory and tactile modalities. Sam is blind and hearing impaired (as a result of Zellweger syndrome) and uses the auditory and tactile modalities. Kris is deaf and blind for four months (as a result of congenital rubella) and uses the tactile modality. Nicole is hearing and visually impaired (as a result of congenital rubella) and uses visual and auditory modalities. Anton is hearing impaired and blind (as a result of congenital rubella), and uses mainly the tactile modality. Thirteen educators (2 mothers, 1 teacher, and 10 caregivers) participated in the intervention, as did three interaction coaches.
Eight interaction categories were used to formulate and evaluate the intervention aims:
1. Initiatives: starting an interaction or introducing something new as part of an answer.
2. Confirmation: the clear acknowledgment that an initiative has been noticed and recognized.
3. Answers: positive (approving) or negative (disapproving) reaction to an utterance of the partner.
4. Turns: turn taking, or becoming the actor, and turn giving, or allowing the other to become the actor.
5. Attention: focusing on the partner, the content of the interaction, or the individuals or objects within the interaction context.
6. Intensity: for the educator, waiting while the child regulates the intensity of the interaction; for the child, appropriate regulation (such as turning one's head away) or inappropriate regulation (such as self-abusive behavior).
7. Affective involvement: mutual sharing of emotions.
8. Independent actions: for the educator, acting while not focusing on the child; for the child, performing actions independently (such as putting on a garment).
The coaches completed a basic interaction course and then received training from the first author in the terminology of the interaction categories and in the DIM intervention protocol. They applied this protocol to monitor and evaluate the implementation integrity of the intervention:
1. Determining the question by identifying the coaching needs of the eduactors on the basis of their daily experiences.
2. Clarifying the question by gathering supplemental information on the child and consulting the educators to determine the questions for coaching, the relevant situations, and the type of coaching.
3. Analyzing the interaction in videotape recordings of the child and educators to formulate the aims of the intervention. An example in Sam's case was adequate reactions, which meant showing confirmation and approving answers more frequently, such as saying "Boom" after Sam had struck the blanket;
4. Implementing the intervention by changing the educators' behavior. Both individual and team coaching are used, with video analysis as the most important tool. The educators learn to recognize the child's utterances, attune their interactive behaviors to those of the child, and adapt the interaction context to facilitate the child's target behaviors. The number of coaching sessions varied across the cases; 10 coaching sessions were provided for Kris, for example, and 4 for Ruud. The number of coaching sessions depended on the complexity of the target behaviors. The number of team coaching sessions was limited for organizational reasons.
5. Evaluating the intervention aims per child and the educators' satisfaction with the intervention process.
OBSERVATION AND DATA ANALYSIS
Old data and new data
In the study, we reanalyzed the data on sustained interaction. The old data included the scores for the following separately observed interaction categories: initiatives, confirmation, answers, regulation of intensity, and independent actions of the educator (Nicole). The new data included the scores for the sequences of sustained interaction in all observation sessions as well as the duration of sustained interaction, the longest sequence, and the mean number of turns in a sequence. Interrater reliability was determined for sustained interaction in 30% of the observation sessions.
The number of videotaped observations differed across the cases. For Kris and Sam, weekly observations were performed during the baseline, intervention, and follow-up with one educator. In the other cases, a single baseline observation and a single observation after the intervention were conducted for each educator. Thus, there were 34 observations for Kris (18 calendar situations, 16 dressing), 14 for Sam (play), 12 for Anton and 8 for Nicole (calendar situations), 4 for Rolf (2 interaction situations with and 2 without materials), and 2 for Ruud (play). For Caregiver 3 in Anton's case, the findings were excluded because this caregiver did not perform the intervention as intended (Janssen et al., 2007).
DATA ANALYSIS AND INTERRATER RELIABILITY
All the sequences of sustained interaction between the child and the educator of at least three turns were recorded in terms of the duration in seconds, the duration of the longest sequence, and the mean number of turns in a sequence. In 30% of all the sessions, two second raters performed a reliability check. For each interaction situation, one second rater was trained until 80% interrater agreement was reached for sustained interaction sequences in three sessions. The interrater agreement varied between 90% and 99%.
Table 1 presents the effects on the mean duration of sustained interaction, the mean duration of the longest sequence, the mean number of turns, and the mean percentage of change in each case. The intervention was effective for Kris (tactile modality) in the dressing situation (see the Discussion). Figure 1 shows the duration of sustained interaction in this situation during weekly sessions. Variability and overlap in the scores were observed. For Sam (auditory and tactile modalities), Table 1 shows that the intervention was effective on all aspects. Figure 2 indicates an immediate increase of sustained interaction after the intervention was introduced and an increasing trend during the intervention. The trend decreased during the follow-up. For Anton (tactile modality), Table 1 demonstrates positive effects on all the aspects. In Figure 3, the plots on the left indicate an increasing trend toward sustained interaction across all the caregivers; the plots on the fight show increased scores after intervention for all the caregivers except Caregiver 5 (see the Discussion). For Nicole (visual, auditory, and tactile modalities), Table 1 shows positive effects for all three aspects. Figure 4 depicts positive effects across all the caregivers. The plots on the right indicate that the intervention effects for Caregiver 4 were already high during the baseline.
For Rolf (visual, auditory, and tactile modalities), Table 1 shows positive effects for the duration of sustained interaction and the mean number of turns in a sequence, but not for the mean duration of the longest sequence (see the Discussion). For Ruud (auditory and tactile modalities), Table 1 demonstrates clear intervention effects for the mean duration of the longest sequence and the mean number of turns in a sequence, but less clear effects for the duration of sustained interaction, which was already high during the baseline.
The DIM had positive effects on sustained interaction across all the cases and communication modalities, except in the calendar situation for Kris. Although the intervention did not directly focus on sustained interaction, it is remarkable that this important quality outcome increased.
Sustained interaction was identified in separate interaction categories like initiatives and answers. Interaction breakdowns were identified during the episodes of intensity regulation and, in Nicole's case, when the educators acted independently. Breakdowns generally occurred more often during the baseline than during the intervention, meaning that the educators and children succeeded in creating sustained interaction during the intervention (see Janssen et al., 2003a).
Despite a positive effect across all the cases, clear differences between individual cases and interaction situations were demonstrated. Positive effects were demonstrated in the dressing situation for Kris, but not in the calendar situation, where the teacher applied the principles of tactile signing by laying her hands on Kris's hands as a signal that it was his turn. Kris, who was not familiar with this signal, paused repeatedly, which caused interaction breakdowns. Only in the last part of the intervention, when the teacher used hand-under-hand contact, was a positive effect seen on sustained interaction.
For Anton, there were substantial differences in sustained interaction with the different caregivers. The results for Caregivers 1 and 2, who received team coaching and individual interaction coaching, were the most effective. For Caregiver 5, appropriate regulation of intensity occurred considerably more often during the intervention than for the other caregivers. Team coaching alone seemed insufficient to improve sustained interaction, in contrast to the results for Caregivers 4 and 6. In Rolf's case, episodes of intensity regulation occurred more often in the situation with materials. The longest sequence was during the baseline. It is important that short sequences of sustained interaction decrease and longer sequences increase within an interaction situation, as in Rolf's case.
The results do not offer sufficient grounds for valid general conclusions, but require replication studies. The interrater reliability for all three categories was satisfactory. In future research, the dyadic category of sustained interaction should be determined as an effect of an intervention using the DIM, in addition to the other interaction categories of harmonious interactions.
IMPLICATIONS FOR PRACTICE
This intervention could be implemented in daily practice. A better attunement to the behaviors of the children improved sustained interaction. To prevent breakdowns, the teacher should wait while the child regulates the tempo and tension or processes information during an interaction (see Janssen et al., 2003a, 2007, 2010). Subtle individual signals of intensity regulation (like turning the head away or picking at a sweater) provide tools to prevent more challenging behaviors. In Nicole's case, the caregivers caused interaction breakdowns of longer periods by spending time searching for a page in the calendar book without communicating with Nicole. In this case, detailed preparation could have ensured that the interaction was sustained.
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Janssen, M. J., Riksen-Walraven, J. M., & Van Dijk, J. P. M. (2003b). Toward a diagnostic intervention model for fostering harmonious interactions between deaf-blind children and their educators. Journal of Visual Impairment & Blindness, 97, 197-214.
Janssen, M. J., Riksen-Walraven, J. M., Van Dijk, J. P. M., Ruijssenaars, A. J. J. M., & Vlaskamp, C. (2007). Team interaction coaching with educators of adolescents who are deaf-blind. Applying the Diagnostic Intervention Model. Journal of Visual Impairment & Blindness, 101, 677-689.
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Marleen J. Janssen, Ph.D., professor, Department of Special Needs Education and Youth Care, University of Groningen, Grote Rozenstraat 38, 9712 TJ Groningen, the Netherlands, and Royal Kentalis, Sint-Michielsgestel, the Netherlands; email:
The study on which this article was based was funded by the Dovenfonds (Netherlands Foundation for the Deaf) and the Stichting Kinderpostzegels Nederland (Children's Postage Stamp Foundation, the Netherlands). We acknowledge the contributions of Nienke Groenendijk and Karen Bril of the University of Groningen and the staff of the Deaf-blindness Department at Royal Kentalis, Sint-Michielsgestel, the Netherlands.
Table 1 Mean occurrences (duration or frequency or both) of the target categories during the baseline (B), intervention (I), and follow-up (F) and the mean percentage of change (% Ch) in each case. Sustained Interaction Longest sequence Case B I % Ch F B I % Ch F Kris calendar 206 172 -17 189 82 59 -44 102 Kris dressing 211 273 +29 267 80 169 +111 150 Sam play 159 239 +50 236 71 127 +79 149 Anton calendar 230 269 +17 87 137 +57 Nicole calendar 202 274 +36 87 150 +72 Rolf without 169 277 +61 86 74 -14 Rolf with 217 267 +23 119 67 -44 Ruud play 264 286 +8 87 108 +24 Mean number of turns Case B I % Ch F Kris calendar 7.7 7.5 -7 8.3 Kris dressing 7.7 22.4 +180 19.8 Sam play 9.9 21 +112 17.5 Anton calendar 8.7 19.4 +122 Nicole calendar 7.2 14.9 +106 Rolf without 10 12 +20 Rolf with 9.6 11.2 +16 Ruud play 11.8 31.5 +162 Note: Percentage of change is the mean increase or decrease of the target behavior during intervention relative to the baseline per case and per interaction situation.
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