Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2011.01414.

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volume 55 part 6 pp 581–595 june 2011

Effects of video-feedback interaction training for

professional caregivers of children and adults with visual
and intellectual disabilities jir_1414 581..595

S. Damen,1,2 S. Kef,2,3 M. Worm,1,2 M. J. Janssen4 & C. Schuengel2,3

1 Bartiméus, Doorn, the Netherlands
2 Clinical Child and Family Studies,VU University Amsterdam, Amsterdam, the Netherlands
3 EMGO Institute for Health and Care Research,VU University Amsterdam, Amsterdam, the Netherlands
4 Special Needs Education and Child Care, University of Groningen, Groningen, the Netherlands

Abstract Conclusions The start of the Contact programme

Background Individuals in group homes may expe-
rience poor quality of social interaction with their
professional caregivers, limiting their quality of life.
The video-based Contact programme may help car-
egivers to improve their interaction with clients.
Method Seventy-two caregivers of 12 individuals
with visual and intellectual disabilities received a
training programme and four individual video-
feedback sessions. Quality of interaction was inde-
pendently measured in an AB-design across subjects
with two baseline and three intervention observa-
tions, using a time sampling coding system for
interactive behaviour as well as a rating for affective
mutuality.
Results From baseline to intervention, significant
increases were found for the frequency with which
caregivers confirmed the signals of clients, for the
proportion of initiatives taken by clients that were
responded to by the caregivers, and the affective
mutuality as a quality of the interaction. No signifi-
cant increase in client responsiveness was observed.
Caregivers evaluated the intervention as useful and
feasible.
Correspondence: Ms Saskia Damen, Oude Arnhemsebovenweg 3,
3941 XM Doorn, the Netherlands (e-mail: sdamen@bartimeus.nl).
coincided with improved quality of interaction
between professional caregivers and clients with
visual and intellectual disabilities in group homes.
Further research is necessary regarding the general-
isability, long-term effects and effects on quality of
life.
Keywords effect study, interaction, interventions,
moderate to profound intellectual and multiple
disabilities, quality of support
Introduction
The satisfaction that people with intellectual dis-
abilities (IDs) have with their life is determined to
a high degree by the quality and quantity of their
interactions with other persons (e.g. Emerson &
Hatton 2008; Miller & Chan 2008). For persons
with disabilities living in group homes, these inter-
actions are mostly with professional caregivers. A
subgroup of clients with intellectual and multiple
disabilities show considerable impairments of social
functioning, often in combination with challenging
behaviour (Lowe et al. 1998). Considering these
social impairments in the context of the quality of

© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
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S. Damen et al. • Effects of interaction training
interaction between clients and their social partners,
the focus for intervention becomes broader than the
interactional skills of the individual client and starts
to include the skills of the caregiving staff and the
organisational support available to develop these
skills with respect to the individual needs of clients
(Heller 2002; Schuengel et al. 2010). Studies on
interventions for improving interaction between car-
egivers and clients with profound intellectual and
multiple disabilities (PIMD) have shown promising
results (see Maes et al. 2007, for a review), but the
empirical evidence is still limited. On the basis of
the results, Maes et al. suggest that improvements in
the quality of interaction would be best made
through a focus on both the clients, staff and the
care organisation. The current study was aimed to
add to the evidence base regarding effective pro-
gramme for supporting professional caregivers in
improving the quality of interaction with clients
with visual and intellectual disabilities.
The skills of professional caregivers to communi-
cate on a non-verbal level are crucial for building
high quality relationships with clients, especially for
those clients who do not use formal language (C.
G. C. Janssen et al. 2002; Janssen et al. 2003b).
Without focused support, professional caregivers on
average appear to have difficulty in adjusting to the
way their client with ID communicates (Bradshaw
2001). However, quality of relationships is deter-
mined not only by effective communication but also
by the mutuality of affect, ideas and activities that
are displayed by both partners. Recognition of
clients’ cues and proper interpretation are the first
steps; choosing and executing an appropriate
response are steps that will have to follow. This
combination of interactive skills has been defined
as sensitive responsiveness (Ainsworth et al. 1978).
Parents and professional caregivers show individual
differences in sensitive responsiveness, and these
differences have been shown to predict differences
in quality of attachment relationships between chil-
dren with or without disabilities and their parents
(De Wolff & Van IJzendoorn 1997; Atkinson et al.
1999; Van IJzendoorn et al. 2007) as well as
between children and their professional caregivers
(Ahnert et al. 2006; De Schipper et al. 2008).
Although generic training and experience with the
client population may be helpful in order to become
more sensitively responsive to particular clients,
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
getting to know the specific signal repertoire of a
particular client will require that caregivers pay spe-
cific attention to that client (Bradshaw 2001). It has
been suggested that attitudes and work ethos of
professional caregivers and the culture of their
workplace are important determinants of the quality
of interactions between professional caregivers and
their clients (Reinders 2010). However, even when
such conditions are adequate and relationships with
other clients are good, there may be individual
clients who present a greater challenge for profes-
sional caregivers to develop a relationship with,
requiring additional systematic and collective effort
on the part of the caregivers.
Intervention methods have been developed that
are aimed at improving interpersonal interaction
between persons with PIMD and their caregivers
(Maes et al. 2007), but few of the programmes have
focused on sensitive responsiveness of professional
caregivers. Golden & Reese (1996) described an
intervention in which caregivers in community-
based group homes were trained using an interac-
tional observation scale in order to discover more
opportunities for positive interactions. Their mul-
tiple probe across group study found small
improvements in positive interactive behaviours of
staff, but no changes in the behaviour of clients
(Golden & Reese 1996). However, sensitive respon-
siveness and mutuality as aspects of social relation-
ship are only weakly reflected in counts and
frequencies of discrete behaviours, and are better
captured by investigating the patterning of interac-
tive behaviour (Ainsworth et al. 1978). In addition
to the development of intervention programmes,
more adequate operationalisations of dyadic interac-
tion quality are needed. One step in that direction
may be to code sequences of initiatives and
responses between clients and caregivers. Another
step may be to adopt or adapt observational rating
scales that are used in developmental and social
psychology research on attachment relationships.
From a dialogical perspective as well, researchers
have been developing observational rating scales for
the co-construction of meaning between caregivers
and persons with PIMD, showing that such scales
can be applied with adequate inter-rater reliability
and can therefore be used to put hypotheses about
interpersonal interactions and the meaning of those
interactions to the test (Hostyn et al. 2010).
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S. Damen et al. • Effects of interaction training
Supporting sensitive responsiveness was included
as an important component of the Contact pro-
gramme ( Janssen et al. 2003a,b), an intervention
programme developed for children who are deaf-
blind and their caregivers. Contact was studied in
three series of single case studies (M. J. Janssen
et al. 2002, 2003a). Results showed improvements
in interaction behaviours of children with deaf-
blindness and their caregivers. The Contact pro-
gramme is offered to teams or networks of
professional or family caregivers when they have
difficulties in establishing good quality interaction
with a child with complex communicative difficul-
ties. Characteristic for interactions between caregiv-
ers and deaf-blind children is that interaction is
almost completely non-verbal, giving rise to misun-
derstandings on both sides (Goode 1994; Bruce
2005). One particular source of misunderstanding
is that blind children do not show facial expres-
sions that demonstrate that the child is paying
attention and is open for communication (Fraiberg
1977). The programme is conducted by an interac-
tion coach trained in the Contact protocol, who
teaches caregivers about interaction and who pro-
vides video feedback to the team as well as to each
individual caregiver. Video is an important change
agent, as has also been shown by Dobson et al.
(2002), who used video to teach staff concrete
behaviours, postures and skills to facilitate commu-
nication with persons with PIMD. In Contact, the
first steps are to identify the problems that caregiv-
ers see with the interaction, and to clarify these
problems in order to arrive at a shared problem
definition. Based on careful collection of informa-
tion on the client, the setting and video observa-
tion, the interaction coach makes an interaction
analysis. This analysis is discussed with the caregiv-
ers in a group session, and caregivers learn that
interactive behaviour exists in different types, that
is, ‘initiatives’, ‘confirmation’, ‘response/reaction’,
‘attention’, ‘turn taking’, ‘regulation of intensity of
interaction’, ‘affective involvement’ and ‘indepen-
dent action’. The caregivers are not required to
frame their problem definition and goals in terms
of this conceptual framework, but the interaction
coach uses this framework in order to be able to
decide when stimulation and reinforcement must
be used to reach the collectively defined goal. In
video-feedback sessions with individual caregivers,
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
the interaction coach stimulates the caregivers to
recognise the signals of the client, to consistently
confirm having noticed these signals (non-visual
evidence that the caregiver is attentive), to discover
how to attune their own interactive behaviours to
those of the client, and to adapt the interaction
context to promote the occurrence of certain inter-
active sequences. In successive sessions, progress in
applying this insight in the relationship with the
client is reinforced by the interaction coach. In the
original Contact programme, the interaction coach
also models interactive behaviour for the caregivers
by working with the client directly, and provides
direct coaching within the interaction situation.
The purpose of the study was to test the efficacy
of the Contact programme for improving the
quality of interaction between professional caregiv-
ers and persons with visual and intellectual disabili-
ties, living in group homes. Changes in quality were
investigated along four aspects of client–caregiver
interaction: (1) confirmation of client signals by the
caregiver; (2) sequences of client initiatives followed
by caregiver responses; (3) sequences of caregiver
initiatives followed by client responses; and (4)
affective mutuality as an overall rating of the quality
of the relationship. The Contact programme was
evaluated by the caregivers with respect to per-
ceived effects of the programme as a whole and ele-
ments thereof, and with respect to ease of
implementation.
Method
Participants and setting
Participants were clients and caregivers of Bar-
timéus, a care organisation for persons with visual
disabilities in the Netherlands. The clients came
from different living units where they lived with
24-h support from professional caregivers. The
study was approved by the local ethics committee.
Participants in this study were 12 clients with visual
and intellectual disabilities. Table 1 shows the char-
acteristics of the participating clients. The age of the
clients ranged from 13 to 54 years (M = 35 years).
Seven clients were male. The severity of ID as well
as the communication level of the clients was
assessed with the Vineland Z scales (De Bildt &
Kraijer 2003). Two clients were diagnosed with
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S. Damen et al. • Effects of interaction training

Table 1 Background characteristics of participating clients

Participant Age Gender Intellectual disability Visual impairment Communication level

1 45 Male Profound Partial sight Pre-symbolic

2 34 Male Profound Blind Pre-symbolic
3 52 Male Profound Blind Pre-symbolic
4 38 Female Severe Blind Symbolic
5 39 Male Profound Partial sight Pre-symbolic
6 13 Male Profound Blind Pre-symbolic
7 16 Male Severe Partial sight Pre-symbolic
8 41 Female Moderate Blind Symbolic
9 54 Male Moderate Partial sight Symbolic
10 19 Female Severe Blind Symbolic
11 30 Female Severe Partial sight Non-symbolic
12 38 Female Severe Blind Pre-symbolic

moderate ID, five with severe ID and the other five
with profound ID. In five clients, partial sightedness
was determined; the other seven clients were diag-
nosed as blind.
The clients were selected based on the following
criteria: (1) professional caregivers desired to
improve the quality of their social interaction with
this specific client; (2) only one client of each living
unit participated in the study; (3) at least seven pro-
fessional caregivers of the client provided informed
consent for participating in this study; (4) the
parents or representatives of the clients gave their
informed consent; and (5) the clients in the group
homes would be informed at their level of under-
standing that videotaping would occur at their
group, and they would respond positively or neu-
trally. Clients with serious behavioural problems,
a hearing impairment or severe epilepsy, were
excluded. Persons with hearing impairments as well
as visual disabilities were excluded, because M. J.
Janssen et al. (2002, 2003a) already studied the
effect of Contact in deaf-blind children. The reason
for excluding persons with severe behaviour prob-
lems or severe epilepsy was that these problems
were considered as causing an additional complexity
for interaction besides the visual and intellectual
disabilities, and that effective treatment of these
problems may already lead to improvement of inter-
action quality.
For each client (n = 12), at least seven profes-
sional caregivers were included at the start of the
study. Table 2 shows the caregiver characteristics.
The final research group of caregivers completing
all the different phases of the study (n = 72) con-
sisted of 13 (18%) men and 59 (82%) women. The
age of the caregivers varied from 20 to 58 years
(M = 30.0 years). The length of their employment
in the current living unit varied from 1.0 year to
22.0 years (M = 4.0 years). The number of working
hours in this unit varied form 10 to 36 h per week
(M = 32.0 h).
Intervention
For the study, two interaction coaches were trained
and supervised by the original developers of the
Contact programme. The implementation of the
Contact programme followed the intervention pro-
tocol developed by Janssen et al. (2003b), with a
number of adaptations. The overall framework was
the same: (1) preliminary group sessions to deter-
mine and clarify the question of the caregivers; (2)
interaction analysis based on information collected
from the group and from observations; (3) interven-
tion sessions consisting of a group session to
analyse the interaction and four individual video-
feedback sessions; and (4) evaluation. In the pre-
liminary phase, the interaction coaches visited
group home staff meetings, informed the profes-
sional caregivers about the intervention programme
and suggested to think if they would have a client
for which they had a question that the programme
could address. In a second meeting, the professional
caregivers, if possible together with family of the

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S. Damen et al. • Effects of interaction training

Table 2 Background characteristics of participating caregivers grouped by client

Years in current
Age group home Working hours/week
Client Male (%) Female (%) M (SD) M (SD) M (SD)

1 3 (43%) 4 (57%) 22.00 (7.35) 4.00 (3.03) 32.00 (2.00)

2 2 (33%) 4 (67%) 29.00 (8.75) 4.00 (3.90) 32.00 (3.20)
3 1 (17%) 5 (83%) 37.00 (11.24) 9.50 (9.34) 28.50 (7.53)
4 1 (13%) 7 (88%) 25.50 (3.74) 3.25 (1.99) 34.00 (2.31)
5 0 (0%) 7 (100%) 33.00 (6.53) 3.00 (1.44) 32.00 (4.38)
6 1 (14%) 6 (86%) 32.00 (10.63) 3.00 (5.47) 14.00 (9.48)
7 2 (40%) 3 (60%) 28.00 (8.51) 2.00 (1.26) 32.00 (5.03)
8 1 (17%) 5 (83%) 33.50 (10.37) 5.00 (4.90) 24.00 (11.83)
9 0 (0%) 5 (100%) 31.00 (9.45) 6.50 (5.92) 24.00 (8.53)
10 0 (0%) 5 (100%) 30.50 (1.41) 4.50 (2.32) 32.00 (2.31)
11 1 (25%) 3 (75%) 26.00 (4.32) 4.00 (1.89) 32.00 (0.29)
12 1 (17%) 5 (83%) 45.00 (11.88) 12.50 (6.31) 28.00 (10.31)
Total group 13 59 30.00 (SD = 9.35) 4.00 (SD = 5.09) 32.00 (SD = 8.01)

client, the psychologist and manager of the team,
would determine the question for interaction coach-
ing. Examples of such questions were: ‘Which
contact initiatives does Tim show during mealtime’,
‘How can the caregivers stimulate turn taking in the
interaction with Melanie?’, ‘When does Samantha
feel understood’, ‘How can caregivers regulate
intensity in the interaction with Peter?’. Similar as
described by Janssen et al. (2003b), an interaction
situation was chosen by the caregivers and this was
used for all video recording (analysis, baseline and
intervention). The coach gathered information on
the client, the client’s relationships with the profes-
sional caregivers and the setting. This was done
using file study, the administration of the Dutch
version of the Vineland Adaptive Behaviour Scales
(De Bildt & Kraijer 2003), interviews and, for each
caregiver, video analysis of the chosen interaction
situation (but the material was kept apart from the
material used for the baseline).
In the intervention phase, a 1-day meeting was
held in which all participating professional caregiv-
ers of one specific client learned more about com-
munication, social interaction and video-feedback
principles, and would analyse the interaction of the
client with the caregivers. Then each individual car-
egiver received four individual video-feedback ses-
sions with the interaction coach over 9 weeks. In
contrast to the original protocol, the type and
amount of coaching were determined beforehand
and not together with the interaction partners.
Compared to earlier implementations of Contact,
the interaction coach was more a facilitator and less
a teacher. In particular, no modelling or coaching
on the job was used, so that the focus of the car-
egivers was fully on developing their own skills in
detecting signals in the clients’ behaviours and in
generating response options and interaction oppor-
tunities. A new element for the evaluation phase
was a final group discussion on how to implement
the results in the participants’ personal care plan.
Design
The study used an AB-design across subjects (cf.
Barlow et al. 2008), in which the subjects refer to
the clients and their team of caregivers in their
living unit. For the 12 clients, both baseline and
intervention started at different moments in time.
The baseline period varied between 5 and 9 weeks.
During this baseline period, two video observations
(T1 and T2) were carried out with each caregiver.
These observations were made in the situation that
interaction coach and caregivers had chosen for
improving interaction. This situation was similar for
all baseline and intervention videotapes with a spe-
cific client and his/her professional caregivers. The
baseline observations preceded the group coaching

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S. Damen et al. • Effects of interaction training

session as well as the individual interaction coach-
ing sessions. The intervention period started with
the 1-day group session, after which the individual
video-feedback sessions followed. The duration of
the intervention was approximately 9 weeks, in
which three video observations were carried out
(T3, T4 and T5) with each caregiver.
Observations were rearranged in random order
before they were rated, so as to keep the raters
naïve to the phase of the intervention from which
the observations were drawn, eliminating the possi-
bility of expectation bias as an explanation for posi-
tive changes. For the statistical analyses, the ratings
were put into their original order again. A drawback
of this procedure was that it was not possible to
fully conform to the multiple baseline design,
because stability of baseline and intervention ratings
could not be established during the experiment
itself. A potential threat to the validity of the find-
ings is therefore the effect of multiple testing.
Each video observation had a duration of 10 min.
Of this material, 5 min was used by the interaction
coach for the video-feedback intervention and 5 min
for the observational coding. These 5-min segments
were selected at random.
Measures
Quality of interaction
First, the variables based on discrete interactive
behaviours are explained. Second, we describe the
construction of the combination scales. Third, the
qualitative rating scale is described. Fourth, infor-
mation is provided on the raters in our study and
the inter-observer reliability.
In the original Contact study of Janssen et al.
(2003a,b), for each child and each caregiver, inter-
vention targets were translated into eight core char-
acteristics of behaviour: initiatives, confirmation,
reactions, turns, attention, regulation of intensity of
the interaction, affective involvement and indepen-
dent acting. The authors reported inter-rater agree-
ments ranging from 83% to 100% across two raters.
The three categories that were most aligned with
sensitive responding were selected for analysis in
the current study: initiatives, confirmation and reac-
tions (see Table 3 for further definitions).
In the next step, these three interaction categories
were transformed into three indicators for ‘quality
of interaction’. The first indicator was the frequency
of confirmation by professional caregivers. Two
other indicators were based on combinations of cat-
egories. The first combination score was the propor-
tion of client initiatives that were followed by either
a confirmation or a reaction of the caregiver. For
example, when a client demonstrated 10 initiatives
in 5 min, of which eight were followed by a confir-
mation or reaction of the caregiver, the proportion
of client initiatives with caregiver response for this
session was 80%. This led to missing values when
no initiatives of clients were observed.
The second combination score was proportion of
professional caregiver initiatives followed by a con-
firmation or reaction by the client. For example,

Table 3 Interaction categories for quality of interaction

Category Definition Examples for client Examples for caregiver

Confirmation Letting the other person know that
his/her initiative was noticed,
through mirroring or imitation
Initiative Attempts to make contact.
Initiatives can be taken every
time an interaction moment is
finished or broken, by the client
or the caregiver
Reaction Responding to the content of the
other person’s initiative
Repeating the words of the
caregiver, returning the smile of
the caregiver
Reaching with hands or arms,
turning the head, seeking eye
contact, talking, smiling, orienting
body to caregiver
Sitting down when asked to by the
caregiver, laughing on the
question ‘do you want to play?’
from the caregiver
The client says ‘meat’, which is
confirmed by the caregiver by
saying ‘you want meat’
Calling client’s name, giving an
object or placing it within reach
Reacting on client’s reach towards
food items by helping him/her to
pick up the food

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S. Damen et al. • Effects of interaction training
when the caregiver demonstrated 10 initiatives in
5 min, of which five were followed by a reaction of
a client, the proportion of caregiver initiatives with
client response for this session was 50%.
In addition to the three quantitative measures, we
used a qualitative rating scale for affective mutuality
(Pianta 1994). In their study on the relation
between child–mother and child–teacher relation-
ships, Pianta et al. (1997) created a scale for rating
affect/intimacy in dyadic interaction of mothers and
children. The Affect/Intimacy scale was later
referred to as the Pianta scale or scale for affective
mutuality (McElwain et al. 2008). The scale assesses
the degree to which caregivers and children engage
in open verbal and non-verbal exchange of emo-
tions (McElwain et al. 2008), from 1 (very low) to 7
(very high). High scores are given when child and
caregiver respond to each other’s emotions, share
positive and negative experiences and the child is
free to express his/her feelings. Low scores reflect
conflict, disengagement or dampening the child’s
emotional expression by the caregiver. The inter-
rater reliability was 0.77 (Cohen’s kappa) in the
original study (Pianta et al. 1997) for three indepen-
dent raters, using exact agreement as the criterion.
McElwain et al. (2008) reached an inter-observer
reliability of 0.87, assessed via intra-class correla-
tions. In the current study, the intra-class coeffi-
cients for the pairs varied for the five measurements
from 0.73 to 0.87 (mean ICC = 0.78).
Because of the length of the data collection
period, the large amount of videotapes and mean
duration of coding one tape (1.5 h for one rater), 12
raters participated in this study. The raters in our
project received a general training on functioning of
people with intellectual and visual disabilities and
principles of social interaction (Trevarthen 1993;
Stern 1998). For each successive client, training
focused on the particular characteristics that could
provide insight into the interactive behaviours and
patterns, such as nature and severity of disabilities,
communication skills, the non-verbal signal reper-
toire and the interaction situation. For training pur-
poses, an extra video recording was made of each
participant in their natural daily living situation,
which was not edited and not used for coaching or
intervention. Training proceeded until coders
reached a minimum of 80% inter-observer agree-
ment on the measures.
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
Each videotape, baseline or intervention observa-
tion was coded by two raters independently, using
event sampling. All the 5-min videotapes were
coded for the use of initiatives, confirmations and
responses. Across the coding period, the inter-
observer reliability rate was checked regularly for
coder drift. When percentage agreement was below
80%, retraining was provided. This happened on six
occasions (out of the 144 reliability checks).
Social Validity Scale
In order to determine professional caregivers’
opinion of the Contact intervention, M. J. Janssen
et al. (2002) adapted the Social Validity Scale of
Seys (1987). Professional caregivers were asked to
rate the components of the intervention on a
5-point Likert scale with regard to subjective effec-
tiveness, effectiveness of single components of the
intervention and workability. The answering options
for subjective effectiveness were very negative (1),
negative (2), somewhat positive (3), positive (4) or
very positive (5). The answering options for the sub-
jective effectiveness of single components of the
intervention were totally not effective (1), not effec-
tive (2), somewhat effective (3), effective (4) and
very effective (5). The answering options for work-
ability were very difficult (1), difficult (2), workable
(3), easy (4) and very easy (5). High scores always
indicated a high social validity; low scores mean a
low social validity. Eighty-two per cent of them
returned the questionnaires (n = 59). A descriptive
analysis on the social validity questionnaire was per-
formed to provide insight on the subjective evalua-
tion of professional caregivers of the video-feedback
interaction training Contact. In the current study,
two sub-scales were used: ‘subjective effectiveness’
(13 items) and ‘workability’ (six items). The internal
consistency of the subscales was adequate; Cron-
bach’s alpha was a = 0.88 (subjective effectiveness)
and a = 0.76 (workability). In addition to these sub-
scales, the scores on four single questions were
examined, which concerned the effectiveness of
parts of the intervention: adjusting the interaction
context, individual video feedback, team video feed-
back and informing caregivers who were not
involved in the intervention. Six per cent of caregiv-
ers did not complete the questionnaires correctly
(incomplete answer and scoring between the 5
points on the scale), resulting in missing values.
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S. Damen et al. • Effects of interaction training
Data analysis
A mean score across raters for the four described
indicators was created as an indicator of quality of
each session for each client–caregiver pair. Caregiv-
ers with incomplete observation records (n = 11)
were dropped from the analyses. The observational
ratings for these caregivers were not significantly
different (P < 0.10) from the caregivers who com-
pleted all assessments. Repeated-measures analyses
of variance were conducted to examine whether the
start of the Contact intervention would be associ-
ated with an increase in the dependent measures
of confirmation, percentage of clients’ initiatives
responded to by the professional caregiver, percent-
age of professional caregiver initiatives responded to
by the client, and affective mutuality. This question
was operationalised by conducting a planned com-
parison of the last baseline observation with the
first intervention observation. In addition, to
examine the effect of ‘testing’ as an alternative
explanation for improvement, a planned comparison
was conducted for the first and second baseline
observation. Additionally, post hoc tests were done
for additional increases or possible decreases after
the first intervention observation. The measurement
occasion (time 1 through time 5) acted as the
within-person factor; the client identification
number acted as a between-subject factor. Including
client number as a between-subject factor con-
trolled for the dependency among assessments for
the caregivers who shared the same client. For the
planned comparisons for testing change on the start
of the intervention, the alpha level was set on 0.05,
achieving statistical power of 0.96 for testing for a
medium-sized effect. For the post hoc test of addi-
tional change between the three intervention phase
observations, alpha was set more conservatively on
0.025. Power dropped somewhat to 0.93. Further-
more, interactions between measurement occasion
and client number were examined as a test of repli-
cation of intervention effect over different clients.
Statistical power for a medium-sized within c
between interaction effects dropped to a more
modest 0.44.
The number of participants available for data
analysis differed for the interaction categories. For
the category, affective mutuality results could be
calculated based on the 72 professional caregivers
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
who were observed in all five measures. However,
for the other three measures of quality of interac-
tion, fewer measures were available, as no meaning-
ful measure could be generated when clients or
caregivers demonstrated no initiatives. This resulted
in missing values across clients and caregivers. For
example, client 12 demonstrated no initiatives
across all of her caregivers, resulting in five missing
values.
Results
Quality of interaction
The descriptive data (Table 4) suggested a general
pattern that the teams of professional caregivers on
average improved their interaction with the clients
after the intervention had started, relative to base-
line. Visual inspection revealed improvements in
confirmation, percentage of client initiatives
responded to by the professional caregiver, and
affective mutuality.
For confirmation, testing the intervention effect
at the level of caregivers, the repeated-measures
anova revealed a significant effect of measurement
occasion (F4,57 = 4.86, P = 0.002). The planned con-
trasts revealed a significant increase between the
last baseline observation for caregivers (T2) and the
first observation after the start of the intervention
(T3; F1,60 = 5.47, P = 0.02; see Fig. 1). The planned
contrast between the two baseline observations
showed no significant change, making it less plau-
sible that the observation sessions themselves led to
improvement. No significant differences between
clients were revealed in the amount or direction of
change in confirmation by the caregivers from base-
line to intervention. During the intervention period,
no further significant changes were found.
For the category percentage of client initiatives
responded to by the professional caregiver, the
repeated-measures anova also revealed a significant
effect of measurement occasion (F4,47 = 3.56,
P = 0.013). The planned contrasts revealed a signifi-
cant increase between the last baseline observation
for caregivers (T2) and the first observation after
the start of the intervention (T3; F1,50 = 5.38,
P = 0.03; see Fig. 2). No significant differences
among clients were observed in this change, no sig-
nificant changes during baseline, and no significant
 589

Table 4 Mean values (and standard deviations) of quality of interaction indicators on T1 through T5 grouped by client participant

Client Variable n T1 (baseline) T2 (baseline) T3 (intervention) T4 (intervention) T5 (intervention)

1 Confirmation frequency 7 0.64 (1.11) 0.14 (0.24) 0.43 (0.61) 0.36 (0.75) 0.29 (0.76)
Initiatives cl confirmed/reacted to by cg (%) 7 50.59 (10.30) 46.69 (11.30) 54.61 (19.89) 51.26 (12.59) 48.41 (9.84)
Initiatives cg confirmed/reacted to by cl (%) 7 42.35 (13.44) 44.09 (11.92) 41.83 (8.11) 42.79 (8.68) 36.14 (12.05)
Affective mutuality 7 4.00 (1.19) 3.29 (1.19) 4.57 (1.13) 4.36 (1.63) 4.36 (0.75)
2 Confirmation frequency 6 0.25 (0.42) 0.42 (0.49) 0.92 (1.11) 0.25 (0.42) 0.75 (0.52)
Initiatives cl confirmed/reacted to by cg (%) 6 39.55 (19.40) 31.53 (24.10) 40.85 (20.23) 40.04 (24.62) 37.73 (8.25)
Journal of Intellectual Disability Research

Initiatives cg confirmed/reacted to by cl (%) 6 42.53 (8.07) 35.08 (6.77) 37.38 (10.09) 38.68 (6.02) 36.72 (11.90)
Affective mutuality 6 4.75 (0.94) 5.08 (1.24) 5.17 (1.13) 5.25 (0.76) 5.00 (1.14)
3 Confirmation frequency 6 1.42 (1.20) 1.00 (1.55) 0.75 (0.88) 1.33 (1.51) 2.25 (1.78)
S. Damen et al. • Effects of interaction training

Initiatives cl confirmed/reacted to by cg (%) 6 41.55 (15.27) 46.74 (23.78) 61.46 (12.82) 49.06 (21.87) 68.50 (21.86)
Initiatives cg confirmed/reacted to by cl (%) 6 61.38 (16.08) 62.92 (11.45) 62.69 (12.37) 54.71 (14.54) 69.24 (11.64)
Affective mutuality 6 4.67 (0.82) 4.75 (0.42) 4.67 (0.41) 5.00 (0.95) 4.75 (1.25)
4 Confirmation frequency 8 6.13 (3.82) 5.19 (3.59) 6.81 (4.11) 6.25 (3.49) 4.31 (2.74)
Initiatives cl confirmed/reacted to by cg (%) 8 70.00 (24.40) 61.21 (35.09) 75.52 (18.27) 82.30 (13.62) 77.70 (15.49)
Initiatives cg confirmed/reacted to by cl (%) 8 56.32 (11.85) 44.47 (14.22) 47.80 (16.90) 54.71 (11.39) 57.17 (17.13)
Affective mutuality 8 4.50 (1.04) 4.50 (1.28) 4.75 (0.60) 4.38 (0.35) 5.06 (0.56)
5 Confirmation frequency 7 0.21 (0.39) 0.14 (0.24) 1.29 (1.35) 0.71 (0.70) 2.07 (2.37)
Initiatives cl confirmed/reacted to by cg (%) 7 48.48 (32.53) 47.04 (28.57) 59.90 (19.83) 56.68 (15.97) 47.59 (29.12)
Initiatives cg confirmed/reacted to by cl (%) 7 43.46 (9.43) 36.18 (6.24) 41.01 (17.26) 39.98 (4.83) 46.32 (11.82)
Affective mutuality 7 4.21 (0.95) 4.36 (1.25) 4.71 (1.19) 4.65 (0.94) 4.86 (0.90)
6 Confirmation frequency 7 2.00 (2.20) 1.29 (1.58) 3.14 (3.11) 3.21 (3.36) 2.36 (1.77)
Initiatives cl confirmed/reacted to by cg (%) 7 56.20 (24.58) 56.26 (26.05) 60.88 (20.27) 71.27 (14.86) 71.49 (18.61)
Initiatives cg confirmed/reacted to by cl (%) 7 45.80 (12.35) 47.46 (17.30) 43.53 (16.47) 43.78 (17.73) 53.73 (22.60)
Affective mutuality 7 4.50 (0.65) 4.43 (0.84) 4.79 (0.81) 4.86 (0.56) 5.00 (0.65)
7 Confirmation frequency 5 5.10 (3.90) 4.30 (2.84) 3.90 (2.84) 1.10 (1.67) 2.80 (1.82)
Initiatives cl confirmed/reacted to by cg (%) 5 68.64 (15.19) 76.75 (8.32) 77.11 (10.60) 85.48 (14.88) 89.08 (12.70)

© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
Initiatives cg confirmed/reacted to by cl (%) 5 60.72 (11.24) 59.56 (17.82) 45.04 (17.17) 55.27 (11.98) 59.73 (21.61)
Affective mutuality 5 4.20 (0.57) 5.30 (0.84) 5.20 (0.57) 4.70 (1.10) 5.30 (0.85)
8 Confirmation frequency 6 6.92 (4.98) 2.25 (1.64) 4.75 (2.30) 5.33 (3.46) 3.33 (0.88)
Initiatives cl confirmed/reacted to by cg (%) 5 83.61 (9.94) 72.00 (25.88) 87.97 (10.38) 84.85 (12.26) 100.00 (0.00)
Initiatives cg confirmed/reacted to by cl (%) 5 61.01 (16.15) 53.77 (8.18) 58.02 (11.34) 46.85 (20.49) 57.15 (18.65)
Affective mutuality 6 4.08 (0.58) 3.75 (1.04) 4.83 (0.52) 4.08 (1.02) 4.42 (0.86)
volume 55 part 6 june 2011
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Table 4 Continued

Client Variable n T1 (baseline) T2 (baseline) T3 (intervention) T4 (intervention) T5 (intervention)

9 Confirmation frequency 5 2.60 (1.82) 5.30 (6.14) 9.10 (10.69) 7.70 (4.15) 10.90 (9.57)
Initiatives cl confirmed/reacted to by cg (%) 3 66.67 (21.6) 66.67 (57.74 66.67 (57.74) 95.83 (7.22) 67.46 (17.87)
Journal of Intellectual Disability Research

Initiatives cg confirmed/reacted to by cl (%) 5 35.22 (8.84) 68.47 (13.22) 46.33 (21.55) 50.77 (18.20) 52.85 (28.51)
Affective mutuality 5 4.60 (0.89) 3.80 (1.25) 4.10 (1.19) 4.80 (1.04) 4.90 (1.34)
10 Confirmation frequency 5 2.40 (0.74) 1.90 (2.22) 4.10 (3.09) 5.70 (2.71) 4.90 (4.17)
S. Damen et al. • Effects of interaction training

Initiatives cl confirmed/reacted to by cg (%) 4 48.64 (30.14) 45.72 (19.06) 55.75 (25.01) 46.82 (8.83) 66.39 (25.17)
Initiatives cg confirmed/reacted to by cl (%) 5 34.45 (20.16) 31.10 (16.28) 45.04 (21.74) 37.75 (9.94) 42.40 (24.55)
Affective mutuality 5 3.20 (1.64) 3.60 (1.56) 4.50 (0.94) 4.50 (1.17) 5.10 (1.02)
11 Confirmation frequency 4 0.88 (0.74) 0.00 (0.00) 0.50 (0.71) 0.88 (0.48) 0.50 (0.71)
Initiatives cl confirmed/reacted to by cg (%) 4 64.53 (19.24) 74.69 (19.06) 82.29 (20.52) 76.00 (24.98) 57.46 (34.46)
Initiatives cg confirmed/reacted to by cl (%) 4 37.23 (11.38) 31.78 (8.82) 31.75 (3.16) 33.20 (10.97) 34.16 (8.86)
Affective mutuality 4 4.00 (0.00) 3.75 (1.04) 4.62 (0.48) 4.13 (0.63) 3.63 (0.95)
12 Confirmation frequency 6 0.67 (1.21) 0.58 (0.80) 1.10 (1.02) 1.50 (1.26) 1.00 (1.14)
Initiatives cl confirmed/reacted to by cg (%) * – – – – –
Initiatives cg confirmed/reacted to by cl (%) 5 54.31 (25.83) 61.83 (27.04) 59.43 (12.81) 45.90 (20.42) 65.04 (14.86)
Affective mutuality 6 2.58 (0.66) 2.67 (0.52) 3.50 (0.63) 3.67 (0.98) 3.58 (1.07)
Total group Confirmation frequency 72 2.48 (3.24) 1.88 (2.91) 3.10 (4.21) 2.87 (3.38) 2.87 (3.89)
Initiatives cl confirmed/reacted to by cg (%) 61 57.01 (23.91) 55.30 (27.47) 64.72 (23.48) 65.50 (23.15) 65.52 (25.14)
Initiatives cg confirmed/reacted to by cl (%) 70 48.18 (16.12) 47.70 (17.66) 46.63 (16.20) 45.71 (14.20) 50.98 (19.64)
Affective mutuality 72 4.13 (1.04) 4.12 (1.24) 4.63 (0.99) 4.53 (0.99) 4.69 (1.01)

© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
* Client 12 showed no initiatives in the tapes T1 through T5.
cl, client participant; cg, caregiver participant.
volume 55 part 6 june 2011
 Journal of Intellectual Disability Research volume 55 part 6 june 2011
591
S. Damen et al. • Effects of interaction training

Figure 3 Percentage of caregiver initiatives responded to by clients

Figure 1 Confirmation frequency for all caregivers across across measurement occasions.
measurement occasions. *P < 0.05 (planned contrast).

Figure 4 Affective mutuality for all caregivers across measurement

occasions. ***P < 0.001 (planned contrast).

Figure 2 Percentage of client initiatives responded to by the

caregivers across measurement occasions. **P < 0.01 (planned
contrast). (T3; F1,60 = 18.22, P < 0.001; see Fig. 4). This effect
was not significantly different for different clients.
No significant changes occurred during baseline,
changes during the intervention period. For per-
making it less plausible that the significant effect on
centage of caregiver initiatives responded to by the
the transition to intervention would be caused by
client, the repeated-measures anova did not reveal a
the repeated observation sessions themselves. After
statistically significant effect of measurement occa-
the initial increase from baseline to intervention
sion (F4,55 = 1.06; n.s.; see Fig. 3). Therefore, no
phase, no further significant increases were found.
further statistical tests were conducted.
For affective mutuality, the repeated-measures
Social validity
anova revealed a significant effect of measurement
occasion (F4,57 = 8.61, P < 0.001). The planned con- All of the 59 responding professional caregivers
trasts revealed a significant increase between the indicated that they subjectively experienced the
last baseline observation for caregivers (T2) and the intervention as effective. Most of the caregivers
first observation after the start of the intervention (63%) rated the effectiveness as intermediate,

© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
 Journal of Intellectual Disability Research
592
S. Damen et al. • Effects of interaction training
followed by small (30%) and large (7% of the car-
egivers). None of the caregivers reported negative
changes. Adjustment of the interaction situation was
rated as an effective component by 84% of the car-
egivers, while 12% of the caregivers rated this com-
ponent as very effective and 4% as slightly effective.
Individual video feedback was rated as an effective
component by 62% and very effective by the
remaining 38%. The majority (74% and 20%
respectively) also reported team video feedback as
an effective or slightly effective component, but
nobody rated this component as ‘very effective’, and
6% even rated this component as ineffective. The
difference in perceived effectiveness of individual
versus team coaching was statistically significant
(Fisher’s exact test P < 0.001). Giving information
to professional caregivers who were not involved in
the intervention was reported as effective by 43% of
the raters. The remaining participants rated giving
information as following: very effective (2% of the
cases), slightly effective (in 33% of the cases), not
effective (17% of the cases) and totally ineffective
(5% of the cases). The majority of caregivers (61%)
rated the intervention as workable, and the remain-
ing answering possibilities showed the following
percentages: very easy (3%), easy (25%), difficult
(10%) and very difficult (1%).
Discussion
The question of the effectiveness of the Contact
programme for persons with visual and intellectual
disabilities living in group homes was answered by
evidence that the onset of the intervention coin-
cided with improvements in important aspects of
the quality of interaction between clients and pro-
fessional caregivers. When clients signalled, profes-
sional caregivers more often provided evidence for
their attention by showing an explicit confirmation
of this signal. When clients took initiatives for inter-
action, they were more often met with a response.
The overall quality of the interaction became more
characterised by affective mutuality. No significant
differences were found for the participating clients
and group homes in the size and direction of
effects. The large majority of care staff also evalu-
ated the programme as effective.
The expectation was that by positively influencing
the responsiveness of the professional caregivers,
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
clients would also become more responsive to the
initiatives of the professional caregivers. No evi-
dence of effects on this aspect of the clients’ behav-
iour was found. One explanation is that the
intervention affected the clients only indirectly,
through the work that the interaction coach did
with the professional caregivers. Perhaps, the
changes in the professional caregivers’ contribution
to the interaction were not strong enough to elicit
immediate changes in the clients. However, some-
times clients may need more time to adapt to
changed circumstances. A longer follow-up period
would be advisable.
Although responsiveness of the clients did not
improve after the start of the intervention, the sig-
nificant improvement in affective mutuality indi-
cated that clients and professional caregivers
showed more harmonious sharing of experiences
and emotions after the start of the video-feedback
intervention. Open sharing of emotions with car-
egivers is a characteristic of attachment security in
children and adults alike (Crowell et al. 2002; Wille-
men et al. 2009). Professional caregivers can be
‘secure-base figure of convenience’ ( Waters & Cum-
mings 2000, p. 168) for children and adults with
(Clegg & Sheard 2002; De Schipper et al. 2006;
Schuengel et al. 2009; De Schipper & Schuengel
2010) or without IDs (Ahnert et al. 2006; Zegers
et al. 2006). For persons with IDs, it is therefore
promising that this aspect of the social and emo-
tional experience is malleable, even in group home
care.
The stability in the mean amount of confirmation
and concurrent responsiveness of professional car-
egivers and the mean scores for affective mutuality
in the intervention period suggests that improve-
ments were sustained. The flip side is that no
further statistically significant improvements
occurred during the intervention period. It should
be noted that effect sizes for changes from one
intervention observation to the next are necessarily
smaller than effect sizes for the change between
having received no intervention and having received
intervention. Larger samples or perhaps more sensi-
tive measures are needed to test for continued
improvement.
In addition, supporting individual caregivers may
not be enough to achieve maximum quality of inter-
action. Factors like physical workload, caregiver
 Journal of Intellectual Disability Research
593
S. Damen et al. • Effects of interaction training
burden and the client-to-caregiver ratio have
demonstrable effects on quality of interaction in
group care for young children without disabilities
(de Schipper et al. 2007, 2009), and may play a role
in group care for persons with disabilities as well.
The observations took place in the daily setting,
meaning that professional caregivers and clients had
to divide their attention. While perhaps higher inter-
active quality is possible if clients and professional
caregivers have more one-on-one time, the current
findings show what can be achieved with respect to
effectiveness under regular circumstances. Finally,
this implementation of Contact focused on optimal
stimulation of professional caregivers to develop
their observational and interactive skills on their
own, with the interaction coach as a facilitator and
reinforcer, but not as an explicit teacher. Future
research may test whether the addition of explicit
teaching of interactive skills leads to additional
effects.
Professional caregivers on average evaluated the
Contact video-feedback intervention as useful and
feasible. Notably, working with professional caregiv-
ers to arrange the setting so that it becomes more
conducive for the interaction and providing indi-
vidualised coaching were deemed as effective, and
may therefore be seen as appropriate given the
concerns that led to the demand for support for
working with their client. Professional caregivers
on average found the programme neither easy to
conduct nor difficult, which might be interpreted as
an indication that the programme was stimulating.
Limitations and further discussions
Although the design allowed for a test whether the
intervention effect differed among the clients, the
statistical power of this test was not strong (0.44)
and the sample of clients small (12). Generalisation
beyond the clients in the study should be carried
out with caution, therefore. However, the large
number of professional caregivers in the study, the
high participation rate among professional caregiv-
ers and the robustness of the effects across clients
and teams lend confidence to the expectation that
the Contact programme might also be effective
for professional caregivers in other group homes.
Further studies are needed to elucidate the personal
or contextual factors that may moderate the effec-
© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd
volume 55 part 6 june 2011
tiveness of the programme (Schuengel et al. 2010),
as well as its long-term effects, and the effects on
interactions with other clients in the living unit.
Furthermore, while the professional caregivers sub-
jectively evaluated the individual video-feedback
sessions as more effective than the group sessions
that started and ended the intervention, the
study design did not allow for an objective test of
the group and individual sessions as separate
components.
Despite these limitations, it is promising to find
that supporting professional caregivers to increase
their awareness of signals and skills for responding
is followed by improved mutuality, affectivity and
intimacy in interactions between caregivers and
their clients, as indicated by the Pianta scale. It
should be noted that an important element of the
Contact intervention is the focused attention by an
interaction coach for individual caregivers. The
interaction coach does not assume the position of
an expert pointing out the faults in caregivers’
behaviour, but supports and reinforces caregivers
while they attempt to discover ways to better attune
to the client. The coaching sessions provide oppor-
tunity for caregivers to become aware of their per-
sonal interaction behaviours and how this influences
the interaction with the client, to work on self-
formulated targets and actually see on video how
changes in interaction style result in a different type
of contact with the client. Although this method
may be more expensive than group-wise coaching,
the professional caregivers in this study appeared to
rate the individual sessions as more effective than
the group sessions. The findings for the Contact
programme as a whole suggest that an empowering
approach to coaching professional caregivers con-
tributes to the efforts that professional caregivers
make to optimise the social participation of the
clients in their care.
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Accepted 25 February 2011