Background
Methods
Participants
Measures
Development of a semi-structured interview schedule
Semi-structured interview
Topic | Number of questions | Primary issues addressed |
---|---|---|
Child’s background | 10 | Basic demographics, level of cognitive ability in relation to scheduling & choice making, communication level |
Preference for routine | 6 | Previous and current ability of child to deal with change, parent’s approach to structuring routines, advice received relevant to routines and how far this was followed |
Use of visuals | 8 | Current use of visuals including consistency of use, parental confidence in use, limitations experienced and child’s preferred modalities |
Routine & change in a typical day | 12 | Walk through a typical day, high and low risk times for child stress, more and less tolerated changes, influence of parents and others on child’s response, use of specific techniques to manage change |
Experience with implementing flexibility | 12 | Previous experience of intentionally increasing variability in routines including procedure used, reasons for doing this, challenges and outcomes |
Behaviours linked to changes | 5 | Type, duration and frequency of behaviours shown by child in response to changes |
Support with family management of behaviours | 7 | Involvement of family members, school and other professionals in strategies that have been implemented by parents for the management of children’s behaviour |
Intervention design | 23 | General anticipated challenges with increasing flexibility and how to avoid these, communication of and content of plans, integrating choice and flexibility into plans, motivation for flexibility, necessary support for parents and others |
Procedure
Analysis
Results
Population characteristics
Design requirements
Theme | Code name | N | % | Kappa |
---|---|---|---|---|
Clear guidance on structure and flexibility is needed | ||||
Variation in professional advice on structure: Structuring routines predominated advice from professionals but varied across families and was not always useful. | Courses/professional advice is useful in managing challenging behaviours | 19 | 52.78 | 1 |
Advised to create a structure or use visuals | 17 | 47.22 | 1 | |
No advice on routines received | 10 | 27.78 | 0.82 | |
Advised to vary structures | 4 | 11.11 | 1 | |
Intervention should include caregiver training and support caregivers to solve problems around implementation | ||||
Caregivers’ experiences affect how they engage with the child: The history of the relationship between the child and their caregivers influences how caregivers manage the environment. | Siblings and peers used to encourage child's engagement | 8 | 22.22 | 1 |
Parents treat child like a typically developing child | 7 | 19.44 | 1 | |
Improved parental management of changes with experience reduces the likelihood of resistance to change | 5 | 13.89 | 1 | |
Caregivers differ in preparedness for supporting children’s flexibility: Parents’ background and experience impacts on their willingness and ability to promote flexibility. | Parents are willing to vary structures | 22 | 61.11 | 1 |
Parent background and education contribute to understanding | 12 | 33.33 | 1 | |
Parents have learned strategies to deal with resistance to change outside targeted training/professional advice/educational background | 8 | 22.22 | 1 | |
Parents are hesitant to intentionally vary routines | 7 | 19.44 | 1 | |
Parental self-efficacy influences ability to introduce flexibility | 5 | 13.89 | 1 | |
Psycho-education for caregivers is important: Integrated support for caregivers, including education would facilitate implementation of the approach. | Caregiver supported problem solving should accompany the approach | 22 | 61.11 | 1 |
Parents’ understanding of cognitive processes underlying child's difficulties helps parents support their child more effectively | 8 | 22.22 | 1 | |
Parents incorrectly mistake transitions and task-completion as resistance to change | 7 | 19.44 | 1 | |
Psycho-education would help parents understand children's difficulties | 4 | 11.11 | 1 | |
Easy to follow reminders /prompts to implement the approach are suggested | 4 | 11.11 | 1 | |
Guidance in evaluating progress and triggers is suggested | 1 | 2.78 | 1 | |
Intervention should support visual planning in way that is appealing to children and can be modified by caregivers to suit the family | ||||
A new approach to visuals is needed: A novel way of using visuals is needed to facilitate long term implementation and utility. | (Traditional) visuals lose impact over time | 20 | 55.56 | 1 |
Visuals are important to support children using a new approach | 16 | 44.45 | 1 | |
Visuals increase rigidity | 5 | 13.89 | 1 | |
Visuals have practical disadvantages | 4 | 11.11 | 1 | |
Families differ in preferences for structure: Structure to routines is sometimes necessary but the level of preferred structure in routines varies across caregiving families and across children. | Family structure enhances naturally occurring variability | 17 | 47.22 | 1 |
Structure is originally driven by child's needs | 16 | 44.44 | 1 | |
Structure is necessary to meet practicalities of family life | 13 | 36.11 | 1 | |
Parents don't like rigid structure | 10 | 27.78 | 1 | |
Parent has a personal preference for structure | 8 | 22.22 | 1 | |
Child implements self-imposed routine | 3 | 8.33 | 1 | |
Flexibility should be imposed in a structured way where possibilities are planned in advance by caregivers and are communicated clearly to the child | ||||
Individuals differ in changes that are problematic: Specific types of changes precipitate challenges, which vary across individuals but can be in expectations, order and/or people. | Child's expectations not being met is upsetting | 19 | 52.78 | 1 |
Parents are aware of the underlying causes of resistance to change | 11 | 30.56 | 1 | |
Changes to fixated rules of order and duration of task/routines are problematic | 8 | 22.22 | 1 | |
Being in the presence of unexpected people is upsetting | 7 | 19.44 | 1 | |
Communication is linked to resistance to change: Communication between child and others can influence resistance to change and how this develops over time. | Child's management of unexpected change improved with age | 15 | 41.67 | 1 |
Increased communication linked to reduced resistance to change | 15 | 41.67 | 1 | |
Child's management of unexpected change worsened with age | 10 | 27.78 | 1 | |
No change in child’s resistance to change with age | 4 | 11.11 | 1 | |
Child's increased ability to communicate is linked with increased resistance to change | 2 | 5.56 | 1 | |
Child's own awareness of the need to be flexible has increased with age | 2 | 5.56 | 1 | |
Increased demands or expectations of what child should be capable of doing with age affects behaviour | 3 | 8.33 | 1 | |
Intervention should incorporate game-like components, which give children perceived control over flexibility and support their choice making | ||||
A game-like approach would motivate flexibility: A game-like approach that incorporates reinforcement (delayed/ social) and perceived control (distancing this from primary caregivers) would motivate children’s flexibility. | Delayed reinforcement is motivating | 15 | 41.67 | 1 |
Unexpected change more tolerable if child perceives that they have some control/input over how it changes | 11 | 30.56 | 1 | |
Change is tolerable if more enticing | 11 | 30.56 | 1 | |
Social praise is motivating | 11 | 30.56 | 0.94 | |
Game-like changes increase compliance | 10 | 27.78 | 1 | |
Change is more likely to be problematic when initiated by primary caregivers than non-primary caregivers | 6 | 16.67 | 1 | |
(Traditional) token economies/delayed reinforcement is not useful | 6 | 16.67 | 1 | |
Delayed reinforcement is contrived | 2 | 5.56 | 1 | |
Support for choice making is necessary: Knowledge of practical alternative choices and support in selecting a choice would promote flexibility. | Child struggles with choice making and processing alternatives | 20 | 55.56 | 1 |
Presenting alternatives is beneficial for preparing child for potential variation | 16 | 44.44 | 1 | |
Familiarity makes tolerating change more manageable | 9 | 25 | 1 | |
Varied choices are required to prevent fixations | 4 | 11.11 | 1 | |
Choices are impractical due to pressure they put on parents | 3 | 8.33 | 0.84 | |
Choices (with no preferential bias by child) are the most naturally occurring and convenient way to introduce flexibility | 3 | 8.33 | 1 | |
Intervention should use technology to facilitate ease of access and adaptation to individual needs | ||||
Technology should support access: A technology-assisted tool that is transportable and can be used flexibly would be beneficial. | Technology as a convenient way of facilitating the approach | 13 | 36.11 | 1 |
Approach should be transportable across people and settings | 4 | 11.11 | 1 | |
Individual adaptation is beneficial: An approach that allows a child to experience achievement on an ongoing basis would be motivating. | Approach should not be prescriptive, there should be an ability to adapt features when needed | 10 | 27.78 | 1 |
The approach should be designed to set the child up for success and generate initial buy-in | 6 | 16.67 | 1 | |
Feelings of achievement are motivating | 5 | 13.89 | 1 | |
Behavioural approaches lose impact overtime | 2 | 5.56 | 1 | |
Intervention should support management of children’s anxiety around change | ||||
Children’s emotions impact intervention needs: Children’s anxiety around change limits flexibility – support for managing anxiety is important | Child needs a chance to process the change | 13 | 36.11 | 0.95 |
Child masks difficulties throughout day | 13 | 36.11 | 0.95 | |
Change more tolerable if child feels safe | 9 | 25 | 0.94 | |
Caregivers reduce warning to avoid the build-up of anticipation anxiety | 6 | 16.67 | 1 | |
Child struggles to identify emotions | 6 | 16.67 | 1 | |
Techniques needed to reduce rumination and anxiety for child prior to change | 2 | 5.56 | 1 |