Addressing disruptive behaviors within naturalistic developmental behavioral interventions: Clinical decision-making,intervention outcomes,and implications for practice

Abstract

Naturalistic developmental behavioral interventions are an empirically supported intervention approach for young autistic children. Despite the prevalence of disruptive behaviors among autistic children, most manualized caregiver-mediated naturalistic developmental behavioral interventions include limited formal guidance on when and how to manage disruptive behavior. The present study sought to characterize how clinicians address disruptive behaviors within the caregiver-mediated naturalistic developmental behavioral intervention, Project ImPACT, the effect of disruptive behavior on Project ImPACT delivery, and the extent to which disruptive behavior impacts social communication outcomes. Data collection was embedded within outpatient early intervention services and included clinicians’ report of adaptations to address behavior within the electronic medical record, child social communication outcomes from 124 children and their caregivers, and interviews with certified Project ImPACT coaches and trainers. Results indicate that close to one-third of Project ImPACT sessions included adaptations made to address behavior and regulation. Furthermore, adaptations made to address disruptive behavior were associated with more adaptations to Project ImPACT overall, although behavior adaptations were not associated with child social communication outcomes. Qualitatively, clinicians described using a flexible approach to integrate content and coaching related to behavior and regulation. The present study indicates several future directions for supporting clinicians in addressing behavior and regulation within the naturalistic developmental behavioral intervention framework.

Lay Abstract

Naturalistic developmental behavioral interventions are a common and well-researched type of intervention for young autistic children that focus on supporting social communication. These interventions often do not include formal guidelines on how to address disruptive behaviors, even though they are common among autistic children. This study measured how often clinicians delivering a specific naturalistic developmental behavioral intervention, Project ImPACT, adapted how they delivered the program to address disruptive behavior, and how these adaptations related to children’s social communication outcomes at the end of their participation in the intervention. We also spoke with clinicians about how they address disruptive behavior and emotion regulation during their sessions. In this study, clinicians adapted Project ImPACT to address disruptive behaviors in about one-third of all sessions. These adaptations did not affect children’s social communication outcomes. Clinicians discussed how they felt social communication, disruptive behavior, and emotion regulation are linked to one another and that they often try to integrate intervention strategies to address each of these areas. However, they note that a clinicians’ approach to addressing disruptive behavior might vary depending on their level of training and experience. These results indicate several future directions for supporting clinicians in addressing behavior and regulation effectively within these types of interventions.

Keywords

disruptive behaviors implementation science interventions—psychosocial/behavioral

Introduction

Naturalistic developmental behavioral interventions (NDBIs) are an empirically supported intervention approach for young autistic children. NDBIs include a number of manualized approaches that share core constructs and strategies and aim to support early social communication skills through naturalistic teaching strategies that build on the child’s current interests and abilities (Bruinsma et al., 2020; Frost et al., 2023; Schreibman et al., 2015). Reviews of intervention studies testing the effectiveness of NDBIs show that these approaches have significant effects on child language, play skills, social engagement, and cognitive outcomes (Sandbank et al., 2020; Tiede & Walton, 2019). When delivered as a caregiver-mediated intervention, NDBIs have positive effects on caregivers’ learning and use of intervention strategies (i.e. caregiver fidelity), resulting in gains in child social engagement and communication skills (Brian et al., 2022; Yoder et al., 2021). NDBIs have grown in popularity over the last decade, with increasing research aimed at demonstrating their efficacy and effectiveness for young autistic children and their families (Crank et al., 2021).

Alongside the use of NDBIs to support social communication skills is the presence of co-occurring externalizing behaviors such as aggression, self-injury, elopement, and behaviors observed during meltdowns. Disruptive behaviors* have been connected to social communication delays and other adaptive difficulties in autism (Park et al., 2012; Williams et al., 2018) and emerge as some of the earliest and most pressing concerns for parents of autistic children (Guinchat et al., 2012) and community providers (Aranbarri et al., 2021). Disruptive behaviors diminish the quality of life of autistic children and their families (e.g. DiGuiseppi et al., 2018; Estes et al., 2013) and can drive difficult and stressful family dynamics (Sikora et al., 2013).

Studies have shown that the prevalence of disruptive behaviors among autistic individuals is consistently higher than in nonautistic populations, although, prevalence rates vary significantly based on the specific behavior, sampling methods, and population from which the sample is drawn. For example, estimates place the prevalence of self-injurious behaviors among autistic individuals at 28% (Rice et al., 2016), while studies of the prevalence of aggression in autistic individuals have reported ranges from 8% to 68% (A. P. Hill et al., 2014). The prevalence of disruptive behavior among autistic children may be related to elevated levels of emotional dysregulation compared to nonautistic populations (Cibralic et al., 2019), and the relationship between emotional dysregulation and internalizing and externalizing behaviors in autistic children (Berkovits et al., 2017). Due to their significance, disruptive behaviors have been the focus of caregiver-mediated interventions, which have shown promise in providing caregivers with strategies to teach safer and more functional replacement behaviors (e.g. Postorino et al., 2017; Scahill et al., 2016).

Despite the prevalence of disruptive behaviors among autistic children, most caregiver-mediated NDBIs do not include manualized approaches or guidelines to manage disruptive behavior (Bruinsma et al., 2020; Schreibman et al., 2015), and only a small number of studies have examined changes in disruptive behaviors or emotion regulation following participation in a caregiver-mediated NDBI (Hendrix et al., 2022). For example, Gulsrud et al. (2010) demonstrated significant reductions in child negative affect and increases in maternal emotional scaffolding throughout the course of a caregiver-mediated NDBI. In addition to examining disruptive behavior as an outcome within NDBIs, Hampton and colleagues (2022) recently used a single case study design to explore the outcomes associated with a caregiver-mediated NDBI that was followed by more explicit support navigating disruptive behavior (Hampton et al., 2022). This research demonstrated that following NDBI strategies with a caregiver-mediated disruptive behavior curriculum resulted in lower caregiver fidelity when implementing social communication strategies (Hampton et al., 2022).

Although important first steps, this research has not yet systematically examined how clinicians make decisions to address disruptive behavior within the implementation of NDBIs, and the impact of these decisions on the delivery of NDBI core strategies. This is an important limitation, as in outpatient contexts, clinicians are seeking to meet the diverse needs of individual children and families and are likely considering many factors when deciding how to deliver NDBI, including presenting behaviors and caregiver priorities (K. Pickard, Wainer, et al., 2023). Indeed, in a recent study from Lee et al. (2023) that characterized the implementation of NDBIs by early intervention providers, caregivers and interventionists discussed disruptive behaviors in 76% of analyzed sessions. Similarly, research conducted within state-funded Early Intervention systems has shown that disruptive behavior has been reported by providers as interrupting the delivery of a specific NDBI, Project ImPACT, within this system (K. Pickard, Hendrix, et al., 2023). However, it is not yet clear when and how clinicians choose to address behavior across a variety of clinical settings.

The present study

The present study aims to address this gap by using mixed methods to characterize how clinicians address disruptive behaviors within a caregiver-mediated NDBI, the impact of disruptive behavior on NDBI delivery, and the extent to which the presence of disruptive behavior impacts intervention outcomes. Specific objectives include using both clinician interviews and data from electronic medical records within an outpatient clinic to: (1) examine clinician-reported adaptation data throughout the delivery of Project ImPACT, a caregiver-mediated NDBI (Ingersoll & Dvortcsak, 2019); (2) explore clinician decision-making around adapting Project ImPACT to respond to and address disruptive behavior; (3) assess the impact of disruptive behaviors on intervention outcomes; and (4) understand the current training that is provided to clinicians on addressing disruptive behavior within Project ImPACT. These aims will help determine key decision points around how and when disruptive behavior is addressed within NDBI, and the impact of these decisions on therapeutic outcomes.

Methods

Procedures

The current study occurred alongside standard clinical care provided within an interdisciplinary outpatient clinic setting housed within a large children’s hospital. Participants seen within the clinic included young autistic children and children with social communication delays. All clinical services centered on the use of Project ImPACT (Ingersoll & Dvortcsak, 2019). Services were provided in a 12- to 14-week outpatient model through in-person or telemedicine services during the COVID-19 pandemic. Telemedicine services were provided using Webex, a HIPAA-compliant video conferencing software. All data collection procedures were approved by the Children’s Healthcare of Atlanta Institutional Review Board (IRB).

Participants

Participants included 124 caregivers of autistic children or children with social communication delays between the ages of 13 and 48 months (M = 30.49, SD = 6.77). The present study excluded any children who may have enrolled in Project ImPACT but completed fewer than eight sessions either due to discontinuation or because they were currently enrolled in programming and had not yet reached eight sessions (90 excluded). Child and caregiver demographic information is reported in Table 1.

Table 1.

Early intervention participant demographics (n = 124).

	Mean	SD	% (n)
Age (months)	30.49	6.77
Average household income by zip code	$62,395	$20,334.72
Sex (male)			72.58 (90)
Ethnicity
Hispanic/Latino			16.94 (21)
Non-Hispanic			82.26 (102)
Declined to report			0.81 (1)
Race
African American/Black			49.19 (61)
American Indian			0.81 (1)
Asian			4.03 (5)
Biracial/multiracial			0.81 (1)
White/Caucasian			37.1 (46)
Unknown/declined to report			8.06 (10)
Interpreter used?
No			89.52 (111)
Yes			10.48 (13)

Nine clinicians participated in qualitative interviews within this study. All participating clinicians were certified Project ImPACT coaches and/or trainers, had master’s or doctoral-level degrees, and had at least 6 years of experience working with autistic children. The demographic information and professional experience of participating clinicians is reported in Table 2. All participating Project ImPACT coaches were sampled from the outpatient clinic in which electronic medical record (EMR) data were collected. All Project ImPACT trainers were sampled from a list of certified trainers. Both coaches and trainers were purposively sampled to represent multiple disciplinary backgrounds including psychology, speech language pathology, behavior analysis, and occupational therapy. Coaches and trainers were approached directly about participation; everyone who was approached agreed to participate in semi-structured interviews.

Table 2.

Qualitative interview participant demographics (n = 9).

	Mean	SD	% (n)
Number of years practicing with autistic children (n = 9)	13	6.63
Number of years as a trainer (n = 6)	4.5	4.09
Sex (female)			100 (9)
Race
White			88.9 (8)
Black and White			11.1 (1)
Professional degree^a
Psychologist			44.4 (4)
Occupational therapist			11.1 (1)
Speech language pathologist			33.3 (3)
Behavior analyst			22.2 (2)
Practice setting
Outpatient autism clinic/hospital setting			77.7 (7)
Schools and early intervention system			11.1 (1)
Private practice			11.1 (1)

One clinician was both a psychologist and behavior analyst and included in both categories.

Intervention

Project ImPACT is an evidence-based, caregiver-mediated NDBI with a focus on supporting social engagement, communication, imitation, and play skills (Ingersoll & Dvortcsak, 2019). Project ImPACT has been researched extensively and is related to increases in child social communication skills, caregiver use of therapeutic strategies, and responsive caregiver–child interactions (e.g. Ingersoll & Wainer, 2013; K. E. Pickard et al., 2016; Stahmer et al., 2020; Yoder et al., 2021). In the current study, Project ImPACT was delivered once per week for 1 h using both in-person and telehealth modalities. Project ImPACT includes materials related to addressing disruptive behavior. This content focuses on incorporating positive behavior supports and is presented as an optional series of additional sessions separate from the program’s core social communication content. Whether and how to incorporate this module is left to the discretion of the clinician (Ingersoll & Dvortcsak, 2019).

Data collection

The present study utilizes mixed methods to characterize adaptations made to Project ImPACT for disruptive behaviors, including data collected as part of routine clinical care and supplemental research procedures. Data collection embedded within routine clinical care included the collection of child sociodemographic information, clinician-reported session-level adaptation to Project ImPACT, and a caregiver report of child social communication skills (see below). Supplemental research procedures included semi-structured interviews with Project ImPACT coaches and trainers.

Interviews with coaches and trainers were conducted by the first author. The first author was a clinical psychology doctoral student familiar to four of the participating certified coaches who worked in the outpatient clinic which is the focus of this study. The interviewer had no previous relationship with any of the other participants. Though the interviewer focused on the perspective of the individual interviewee and used a semi-structured interview guide (included in Supplemental Materials), it should be acknowledged that both the interviewer and the senior author who supported the study design had experience administering Project ImPACT and their own clinical perspective and biases. The interviewer is currently a trainee in clinical psychology and approaches emotion regulation with an emphasis on developmental and co-regulatory processes. The senior author is a certified Project ImPACT trainer and psychologist within the outpatient early intervention clinic with training in multiple NDBI approaches. In light of these biases, this study sampled participants from multiple disciplinary and theoretical backgrounds to ensure a variety of clinical perspectives.

Measures

Caregiver and child demographic information

Demographic information for each participating caregiver and child was collected as a part of routine care. This included a child’s age at program entry, the race and ethnicity of children and their caregivers, child sex, and family zip code which was used as an indicator of socioeconomic status.

Social communication checklist

Caregivers completed the Social Communication Checklist (SCC) upon Project ImPACT entry and completion. The SCC is a 70-item checklist that is broken into four major domains: (1) social engagement; (2) expressive communication; (3) receptive communication; (4) imitation; and (5) play. Within each domain, items are listed in a developmental sequence and caregivers are asked to report whether their child engages in each skill: (1) rarely or not yet; (2) sometimes but not consistently; or (3) usually (at least 75% of the time). Previous research using the SCC has demonstrated its reliability, sensitivity to change within caregiver-mediated interventions, and association with other measures of social communication (Wainer et al., 2017). The present study focused on the Social Engagement and Communication domains of the SCC.

Clinician-reported intervention adaptations

Clinicians reported adaptations made to each Project ImPACT session via charting in an EMR template. Specifically, clinicians reported making any of eight types of adaptations, informed by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME; Stirman et al., 2019). Categories included: (1) adding program content (such as psychoeducation related to autism); (2) repeating session content; (3) dropping demonstration of strategies by the coach; (4) dropping coaching a caregiver in the strategy; (5) shortening the session; (6) removing the practice plan; (7) adapting the session due to behavior; and (8) any “other” adaptation.

Clinician interviews

Semi-structured interviews with Project ImPACT coaches and trainers focused on clinical decision-making around addressing disruptive behaviors in session. Specific questions focused on situations that drove clinicians to address disruptive behaviors, how they addressed the disruptive behaviors (e.g. via the use of formal content or providing informal information), the perceived impact of addressing disruptive behaviors within Project ImPACT, and how they balanced needing to address disruptive behavior while also delivering core social communication strategies. In addition, Project ImPACT trainers discussed their experiences training and supervising clinicians and the extent to which behavior is covered or discussed in these teaching contexts. All interviews were conducted via Zoom and lasted between 23 and 51 min (M = 32.88, SD = 9.5). The interview guide is included in Supplemental Materials.

Data analysis

Quantitative analysis

Clinician-reported adaptation data were used to examine the prevalence of behavior adaptations throughout the delivery of Project ImPACT. Due to violations of the assumption of normality, a series of non-parametric Kruskal–Wallis Tests were used to compare overall adaptations made to Project ImPACT and child social communication outcomes among: (1) children for whom there were no adaptations for behavior made throughout Project ImPACT; (2) children with one Project ImPACT session that was adapted to address behavior; and (3) children with multiple adaptations focused on behavior. Child social communication outcomes were calculated as change scores on the Social Engagement and Communication domains of the SCC.

Qualitative analysis

All interviews were conducted via Zoom videoconferencing software, recorded, and transcribed verbatim. Rapid qualitative methods were used in which the lead and senior authors E.K. and K.P. debriefed following each interview to rapidly summarize key themes and to adapt interview protocols in response to new and relevant information (e.g. the need to ask more nuanced questions regarding emotion regulation processes). This rapid debriefing approach was used to expedite qualitative analyses by using themes from rapid debriefing to inform a preliminary codebook (Beebe, 1995; Vindrola-Padros & Johnson, 2020). Rapid qualitative methods also ensured that saturation was reached by reviewing debrief forms to ensure no new themes were emerging.

Once saturation was reached, all transcribed interviews were uploaded into MAXQDA software and formally analyzed using the preliminary codebook and a conventional content analysis approach to identify new codes that may not have been included in the rapid debrief codebook (Hsieh & Shannon, 2005). Content analysis allowed for a more deductive approach to coding in which many themes directly related to the questions that were asked within the interview protocol and, thus, were grouped together in this way. Qualitative analysis included E.K. and K.P. applying the preliminary codebook to an interview, meeting to review the coded transcript, revising the codebook based on emergent themes not included in the initial codebook, and coming to a consensus on any discrepant codes. After coding, categorization occurred in which the research team met to organize codes into overarching themes based on the key interview questions. For example, content analysis was used to describe the decisions clinicians weighed when choosing how to address a child’s behavior and support regulation, the process by which they did this, the perceived outcomes of directly supporting regulation and addressing behavior, and the needs of community clinicians. All results were presented to clinician participants to ensure the accuracy and appropriate application of findings.

Mixed methods integration

Quantitative and qualitative data for the current study were collected simultaneously and used to examine the convergence or divergence of results around each study aim. All qualitative and quantitative results are presented together and grouped by research aim.

Community involvement statement

The current study included qualitative data collection and member checking from clinicians supporting young autistic children using Project ImPACT. Stakeholders were not involved in other aspects of the research project.

Results

Quantitative and qualitative results are presented for each specific aim. All qualitative categories, themes, and definitions are presented in Table 3.

Table 3.

Primary qualitative themes and definitions.

Theme	Definition	Example quote
Decisions Weighed
Caregiver priority	Participants shared that they make decisions based on whether disruptive behavior and/or regulation was a priority to caregivers.	“It doesn’t help to work on something the family isn’t interested working on. So, I mean just like the goals in Project ImPACT and what we target and as we move through, if a family is not interested, it’s not going to help or make a difference. So those decisions are really based on family input and what they’re telling me is the most significant thing for them.”
Intensity	Decisions made based on the intensity of the behavior (e.g. whether it posed safety issues).	“I had a situation a while back where the child was actively headbanging through the whole session. And we didn’t really have time to stop and say, well, let’s talk about it next week after we get through this chapter. We really had to dive into it about keeping the child safe while also making sure we weren’t unintentionally reinforcing the headbanging.”
Interference	Decisions to address behavior when it interferes with the ability to cover core Project ImPACT content.	“If it seems like the challenging behavior is pretty significant, like it would get in the way of being able to have a successful run of Project ImPACT, then I will start with the new challenging behavior module . . . if it seems like that’s going to be pretty interfering.”“I also think a lot about how those behaviors get in the way of learning, whether it be, it truly does impact or reduce a child’s opportunities to learn, but also when the parent might feel less competency or might feel less engaged, and then that reduces opportunities for learning.”
Occurrence and timing
At the start of program	Addressing disruptive behaviors prior to teaching Project ImPACT strategies.	“I probably address it more towards the beginning because otherwise, early on when I started to see kids in Project ImPACT, when I didn’t address it right away, it was just this thing that kept holding us back because mom felt like. . . For one child, for example, he would bang his head at home but then the first couple sessions, I didn’t see it. But in mom’s mind, anytime we would try to make a practice plan, her feedback coming back was we tried that but then he started to bang his head or fell to the ground. So, you could tell that was her main concern. Even though she was trying her hardest to do bottom of the pyramid support, she’s kind of like ‘I have to first keep him safe and he’s not safe.’”
As behavior or regulation challenges arise	Making decisions to address disruptive behaviors as they arise within Project ImPACT sessions.	“A lot of times it can just be real quick, informal conversation. We might be doing a session on following the child’s lead and then mom mentions, ‘Oh, he had a meltdown in school today.’ Maybe we talk for just five minutes on what might have caused the meltdown. Oh, there was a change of routine, that could have contributed or something like that. So sometimes if the parent’s bringing something up, we’ll briefly discuss it.”
At the conclusion of program	Covering strategies to address behavior and regulation after completing Project ImPACT core content.	“When we choose to do the behavior chapter it’s often at the end because otherwise, maybe child is having behavior in other settings. But as far as our Project ImPACT sessions go and what parents are reporting to me as far as practice during the week, the behavior is not impacting those things.”
Providing caregivers with a choice	Participants describe that they give choices to caregivers on how and when to address behavior.	The way that I’ve structured it is when we’ve been moving through the pyramid [Project ImPACT strategies] at our typical pace and then the behaviors are starting to come up. . . So, for example, ‘how did practice go?’ And they [the parent] tell you, ‘The tantrums have gotten out of control,’ right? And so, we make decision points with the family. I’ll say ‘here’s the current content that we were talking about. We were going to be moving into how we set up situations to pull for new communication related to that goal that we set. You’re also bringing up that these tantrums are really challenging right now. We have a couple different options. Do you want to keep moving on the path that we were going, or do you want to take a pause and have a conversation for this for this week and maybe next week [about the tantrums] and then return back to where we were going?’”
Description of approach
Pacing Project ImPACT strategies	Participants reporting that they increase their use of developmental strategies and decrease their use of behavioral strategies to support regulation within Project ImPACT.	“When there’s behaviors during a session and it’s keeping the parent from interacting, then I typically pause and think about which impact strategies that we can really focus on to help with behavior. And typically, it’s at the bottom of the pyramid and focus and adjust. Just following the child’s lead, seeing what their idea is, trying to determine their interest, and then using that in a session.”
Embedding informal behavioral supports	When information about behavior supports are briefly covered within Project ImPACT sessions alongside other content.	“So, we’ve been talking a lot about functions of behavior and how to respond to it differently depending on what we think the purpose is. So potentially removing the attention entirely from the jumping and then praising him when he stops jumping or giving him something appropriate to jump on like a trampoline that he has at home or something like that. So that’s one example where I didn’t necessarily assign the chapter ahead of time but it came up during the session, so we just talked about it.”
Formal teaching of positive behavior supports	Having dedicated sessions to deliver the positive behavior support module within Project ImPACT	“If the family really prioritizes it or if I’m getting a sense from talking to the family and/or observing with the child that they really are going to struggle and maybe be having tantrums and crying throughout most of our sessions to the point where we won’t be able to even work on a lot of the social communication stuff, then I’ll just start off the bat with the full challenging behavior module.”
Clinical experience and prior training	The role of a clinician’s background in their comfort and approach to addressing behavior and regulation within Project ImPACT.	“There have definitely been times that I’ll incorporate tools that fall outside of Project ImPACT. I don’t know that Project ImPACT really talks about coping skills and how those things can be used to address behavior. So as a psychologist I have a broader behavioral intervention background. So, I definitely feel like I pull from multiple perspectives. I think about functions of behavior from a behavioral perspective. But we’ve also been talking recently about emotion regulation and how we support that for kids and how is that impacting some of these things.”
Emotion regulation
Emotion regulation as a foundation to learning	Participants describing that regulation serves as the foundation for engagement and behavior	“I use some of the Project Impact behavior a little bit. But you’re right when you say it’s there. We didn’t really touch on it a ton as much as we did everything else. So, it would have probably been nice to have more focus maybe a day or two days focused on behaviors because I think that there are so many great things that happen in that pyramid. But if we’re having dysregulation or behaviors were not going to get there. This pyramid isn’t going to work if the child is having behaviors or the dysregulated.”
Regulation is implied but not named	Description that regulation is implicitly supported within Project ImPACT through its emphasis on pacing the use of strategies to support engagement.	“I think [emotion regulation] is incorporated to some extent, like as you’re thinking about following your child’s lead or shaping the interaction, you’re doing a lot of it naturally. You’re using a soothing voice, you’re giving them space when they want space, and matching where they’re at, meeting them where they’re at. I think there is some of that naturally built in. But then when it comes to the behaviors coming out, that’s not a way something is explicitly acknowledged could be part of the antecedent. They were really upset about something, or they were really tired or they were hungry or they were transitioning away from a caregiver or something like that. So yeah, I think that there’s room to acknowledge it in the framework.”
Role of behavior in Project ImPACT fidelity and adaptation
Adapting Project ImPACT when behavior or regulation challenges are present	Descriptions of how Project ImPACT is adapted to accommodate discussion and/or formal teaching around disruptive behavior or regulation.	“If it’s . . . a more severe tantrum and it’s really distressing to the child, it’s really distressing to the family and it’s not something that’s going to be recovered in 10 minutes, then I’ll usually just ask, “Hey, it seems like we’re having a hard day today, do you want to take a pause here and reconnect later today or later this week?” But I try my best not to do that because I think part of coaching autistic kids is this kind of stuff happens a lot and I don’t like to cut our sessions short because I feel like it’s part of my job is to help them navigate this stuff. And it is something that parents are really looking for as well. So I try to only reserve that if it’s a really extended tantrum or the family is. . . Or sometimes they’ll ask, “Hey, can we stop for today,” and of course, yeah.”
Adaptations aligned with Project ImPACT fidelity	Participants sharing how Project ImPACT fidelity can be maintained while also addressing behavior.	“In terms of fidelity, I think you can still address most of the things on the fidelity checklist while you’re addressing challenging behavior. So, like I said, part of shaping interaction is balancing when you should be relying more on the bottom of the pyramid and using engagement strategies and helping the child to regulate. So, if the child is dysregulated, part of shaping the interaction is going back down to the bottom of the pyramid and helping them self-regulate. And so, I think you can do that and coach parents to do that within the framework of the Project ImPACT.”
Outcomes
Caregiver buy-in	Perceptions that there is increased caregiver buy-in for Project ImPACT when behavior is also covered.	“Because it comes up as such a concern for parents, I think my language has shifted more toward, you know, the focus is really on this, but we might be able to talk about it. And more like I see this as a major presenting concern for you even if it may not be my major presenting concern for this child, and so let’s make sure that we integrate it, to also think about is that going to increase parent buy in so that we can also work on other skills that are going to be helpful for her social communication skills.”
Caregiver knowledge and confidence	Increased caregiver knowledge and confidence in managing behavior and regulation when it is covered.	“I think a bigger thing is parents having more empowerment so they feel like they have tools and strategies that they can use. And then I think the other really positive thing is understanding why that behavior is happening. So many times, parents will say they just don’t understand why their kid has a meltdown because of x, y, or z. And when we really break it down and look at what’s happening before or what’s the result of that behavior, then parents are better able to understand that the child isn’t misbehaving on purpose or that there are reasons and that as the adults, we can put things in place to help the kid get through things or do what they need to do or whatever.”
Social communication outcomes	Perceptions that there may be greater social communication gains when behavior is addressed because children and familiar are now able to get more out of core Project ImPACT content.	“I think when you do address the behaviors it can lead to much better outcomes because it makes playtime more effective, more fun for the child when they’re able to fully participate. I’m thinking of one child I had who the first couple sessions he was screaming the whole time because he didn’t have another way to communicate that it wasn’t fun for him. But as soon as we talked about a more effective way to ask for what he needed and rewarded positive behaviors, it made playtime easier and then he ended up having really great social communication outcomes because then mom was able to more effectively follow his lead and use all the other strategies that we talked about.”
Community need
Frequency of support provided to community providers within training and consultation		“I think we spend a lot of time in consultation talking about challenging behaviors. . .When you’re doing the case support in consultations, that’s where the providers are like, ‘okay, this child just runs and runs and runs and runs and how do I coach this parent?’ So I feel like it’s kind of those tricky cases that tend to be the ones that are discussed in consultations where providers feel like they’re not sure what to do.
Clinician experience	Community clinician experience impacts the frequency with which behavior questions come up in consultation.	“I was supporting a person I was training, and their comfort wasn’t in behavior. And so, when they had a concern, I had to spend a lot of one-on-one time on the module and I almost felt like I was doing a behavior one-on-one, teaching them. That was interesting to me because they wanted to support the parent, but they didn’t feel super comfortable.”
Need for decision points	The need for more explicit guidance on how and when to address behavior and regulation within Project ImPACT community training.	“I went through the training in 2015 and that was before the challenging behavior module was added. And then I did the Project ImPACT training for the second edition in 2020 but it was telehealth and it was right in the beginning of the pandemic. So, [the challenging behavior module] couldn’t be demonstrated. So, I think that that’s something that is a great area of growth for Project ImPACT.”

Decisions weighed around addressing disruptive behaviors

Trainers and clinicians described that the need to address disruptive behavior was common within their delivery of Project ImPACT yet not universal to all children served within the program. Three main themes emerged related to clinical decision-making regarding when and how to address disruptive behavior.

Caregiver priority was the most prominent of these themes and was described universally by clinicians and trainers as a reason to incorporate positive behavior supports within Project ImPACT. Caregivers were reported to express priorities surrounding disruptive behaviors or emotion regulation within collaborative goal setting, or as roadblocks emerged within the program. Clinicians and trainers perceived that caregivers’ priorities were rooted in the stress and negative impact that the disruptive behaviors had on children, caregivers, and other family members. As one trainer stated,

Anytime we would try to make a practice plan, [the mother’s] feedback was we tried that but then he started to bang his head or fell to the ground. So, you could tell that was her main concern. Even though she was trying her hardest to do bottom of the pyramid [developmental] support, she’s kind of like I have to first keep him safe and he’s not safe.

Caregivers’ priority to address their child’s behavior and regulation often but not always corresponded to the intensity and interference of the disruptive behavior and/or dysregulation. Clinicians and trainers consistently described that self-injury, extended tantrums, and aggression such as hitting, biting, and kicking could be reasons to formally address behavior and regulation (i.e. intensity). Many of these more intense behaviors were described as important to address because they also interfered with the ability to deliver therapeutic content within Project ImPACT (i.e. interference).

For families for whom we do the behavior chapter . . . that’s because we are having a harder time getting through sessions . . . If the child has a tantrum that lasts for 30 minutes, that’s definitely something that impedes our ability to get through the program and for parents to practice as much as we’d like them to and to feel comfortable with the techniques that they’re learning.

The frequency and timing of adaptation to address disruptive behavior

Occurrence and timing of behavior adaptations in EMR

Of the 124 participating families, 35.5% (n = 44) had at least one Project ImPACT session in which an adaptation was reported to address disruptive behavior, with 21.8% (n = 27) of families having two or greater Project ImPACT sessions adapted to address behavior. When Project ImPACT was adapted to address disruptive behavior, an average of 3.08 sessions (SD = 2.75) were adapted during the program, according to the clinician report. Of all the adaptations to Project ImPACT that were reported by clinicians, behavior adaptations accounted for 21.3% (n = 135) of adaptations. Adaptations appeared somewhat more prevalent in the middle sessions of the program, with 37.8% of reported behavior adaptations occurring across the first and last three sessions of Project ImPACT, respectively, and 59.3% of adaptations occurring in the middle six sessions.

Qualitatively, trainers and clinicians described addressing disruptive behaviors and emotion regulation at various points in the Project ImPACT program, including at the start of the program (immediately following collaborative goal setting), as behavior or regulation challenges arose within Project ImPACT, and at the conclusion of the program. As one clinician noted, “Sometimes . . . those behaviors happen really early in the program and then sometimes we’re almost done, and we wait and tack them on as an extra thing.”

In many instances, clinicians noted providing caregivers with a choice about the timing of when behavior could be addressed and using their preferences to guide clinical decision-making:

Our sessions were going pretty well . . . but mom had expressed that at home [her child was] throwing toys and different things and running out the front door. And so I just asked her if that’s something she’d want to focus on before we went on to the next strategy and she said yes.

Description of approach to addressing behavior and regulation

Within the EMR, clinicians were prompted to describe each adaptation to Project ImPACT, including those related to disruptive behavior. When a behavior adaptation was indicated in the EMR, clinicians described specific strategies that they used to address behavior, such as antecedent-based strategies and planned ignoring. Clinicians accomplished this through a combination of coaching on behavioral strategies, didactics, environmental modification, and planning with caregivers on how to best incorporate strategies in the home.

Within the context of interviews, clinicians and trainers described a flexible approach to addressing disruptive behavior and emotion regulation within Project ImPACT. Most often this included attempting to support regulation and behavior through pacing the Project ImPACT developmental and behavioral strategies. For example, participants noted that they coach families to adjust their affect, to follow their child’s lead, and to modify their environment in response to the child’s behavior or regulation needs. One participant described this as:

I try to slow things down for the family, talk a lot about modeling regulation, using animation, when our child is overregulated, we want to bring ourselves down to help them calm themselves. So, returning to the bottom of the pyramid [developmental strategies] . . . or letting them have a break before we rejoin.

In addition to the pacing of strategies embedded within Project ImPACT, many participants also shared that they embed informal positive behavior supports within Project ImPACT sessions by discussing ways to address or navigate disruptive behavior as it arises but not using formal modules or teaching:

[In my sessions] I will say things like, “I wonder what just happened that made him want to get up and leave. What can we do?” So, I think there’s a natural way to embed that when you’re teaching without specifically saying, “We are talking about behavioral strategies now.” I think that’s the issue in our field—that we separate. Like oh, if you have a behavior [that’s getting in the way], we’re going to talk to you about behavioral strategies. In actuality, we should be providing those types of supports throughout.

Finally, in some instances, clinicians described dedicating entire sessions to formally teach positive behavior supports using the modules embedded within Project ImPACT, including the forms and activities within the modules. As one clinician described, “It’s one chapter but it’s supposed to be four or five different sessions, and I tend to condense them into more like three sessions.”

Clinicians and trainers consistently noted that their approach to addressing behavior was influenced by their clinical experience and prior training. For example, clinicians with greater background in behavioral approaches, including psychologists and behavior analysts, indicated feeling confident embedding positive behavior supports or regulation strategies within Project ImPACT, whereas clinicians without formal training indicated leaning on the modules to support families in these areas. One clinician described the impact of their background and training on how they address behavior as:

There have been moments that are disruptive . . . when kids have severe and frequent disruptive behaviors, and it feels like they need more support than what I can give . . . For most kids though, I do feel like the training that I got, it has been enough to give the parents . . . a starting point.

Clinicians were asked explicitly about similarities and differences in their approach to supporting emotion regulation in contrast to the emphasis that is often placed on behavior. Many clinicians and trainers clearly described the overlap between regulation and behavior and the way that both unfold within Project ImPACT sessions. For example, one clinician stated,

Sometimes the behavior can start off [with] this child was throwing a toy because they clearly wanted a reaction from a parent. But then it escalates and escalates, and now they’re so upset that they can’t bring themselves back down. And now it’s not about attention anymore. They just need support regulating themselves.

Given the perceived relationship between regulation and behaviors such as throwing, elopement, and aggression, clinicians often noted the importance of supporting regulation first and as a foundation for engagement. Clinicians described the importance of regulation for any individual to enjoy themselves, to engage in their world, and to learn:

But first of all, just making sure that they’re regulated. So, we go all the way back before we even start [to] just meeting your child where he is and just making sure is the environment a mess, are they overstimulated, okay, let’s take this down.

The impact of disruptive behaviors on Project ImPACT fidelity, adaptation, and social communication outcomes

Behavior adaptations and other program adaptations

Kruskal–Wallis tests were used to compare all reported adaptations (e.g. repeated content, shortened sessions) across groups of children who received: (1) no adaptations for behavior: (2) one session that was adapted for behavior; or (3) two or greater sessions that were adapted for behavior. Prior to running these analyses, a combination of one-way analyses of variance (ANOVAs), chi-square tests, and Fischer’s exact tests was used to compare each behavior adaptation group on all demographic variables reported in Table 1. Results of a one-way ANOVA show that behavior adaptation groups differed significantly on age (F(2, 121) = 3.17, p = 0.05). Specifically, a Tukey’s post hoc test revealed that children who received no behavior adaptations were significantly younger (M = 29.4, SD = 7.22) than children who had two or greater sessions that were adapted for behavior (M = 33.0, SD = 5.29). Groups did not differ on any other demographic variables.

As shown in Figure 1, results of a Kruskal–Wallis test demonstrate significant differences in total Project ImPACT adaptations across the three behavioral adaptation groups (H(2) = 9.14, p = 0.01). Specifically, Dunn’s post hoc test with Bonferroni corrections revealed that there were significant differences between children with no behavior adaptations during their participation in Project ImPACT and children in which two or greater Project ImPACT sessions were adapted (p < 0.05) (Figure 2). In terms of differences in specific adaptations, children with two or more behavior adaptations also had more sessions in which direct caregiver coaching was dropped (H(2) = 9.76, p < 0.01) and more adaptations marked “other” (H(2) = 12.52, p < 0.01). Dunn’s post hoc tests with Bonferroni corrections revealed that these differences were driven by significant differences between children with no behavior adaptations and children in which two or greater sessions were adapted for behavior (ps < 0.01).

Figure 1.

The number of total program adaptations by the prevalence of behavior adaptations during the implementation of project ImPACT.

Figure 2.

Proportions of types of program adaptations by the prevalence of behavior adaptations during the implementation of project ImPACT (Ingersoll & Dvortcsak, 2019).

Qualitative data from clinicians and trainers were consistent with data from the EMR in that many clinicians and trainers indicated the need to adapt Project ImPACT when behavior or regulation challenges were present and/or addressed within sessions. Most often, clinicians reported having reduced time in the session to coach caregivers when behaviors were present or the need to extend the duration of the program to accommodate addressing regulation and behavior supports more formally.

I do think that the presence of disruptive behaviors is going to impact how much we accomplish. . . . Sometimes the kids that have really significant difficulties in transitioning into the building, off the elevator, waiting in the waiting room . . . So, I think disruptive behaviors around that can be difficult because then it can make the startup to get into the room take longer and . . . it takes away time to coach and cover the content we are hoping to teach parents.

Although behavior adaptations reported within the EMR were associated with other adaptations to Project ImPACT, trainers and clinicians perceived that adaptations to address behavior and regulation were often aligned with Project ImPACT fidelity even if they resulted in other adaptations to the program.

I do think doing some of that behavioral support is within the scope of Project ImPACT. It could be considered [part of] fidelity. But in terms of thinking about fidelity through the individual session, you might not get through the session content that you planned for that day if you’re focusing more on a disruptive behavior or . . . you might step back to session three or so when you’re talking about . . . how are we going to set up the room. You might double back to that if there’s behaviors coming up. Or you might say hmm, ‘let’s put today’s lesson on hold while we talk about this other thing,’ which is not to say you won’t just do it the following week.

Behavior adaptations and program outcomes

We sought to assess how adapting Project ImPACT to manage disruptive behavior related to children’s social communication outcomes. Notably, only a subset of the full sample had social communication scores on the SCC at both the beginning and end of intervention participation (n = 64). There were no significant differences in demographic characteristics across children with and without SCC data, and across groups of children with no behavior adaptation, one behavior adaptation, and two or greater behavior adaptations. Kruskal–Wallis tests indicated that there were no significant differences in Social Engagement or Communication change scores across children with no behavior adaptation, one behavior adaptation, and two or greater behavior adaptations (H(2) = 1.28, p = 0.53; H(2) = 2.75, p = 0.25).

Qualitatively clinicians and trainers perceived that addressing behavior and regulation helped to promote caregiver buy-in for the program by ensuring that their goals were validated, addressed, and seen as clearly impacting a child or family’s quality of life. One clinician described caregiver buy-in as:

They are very happy and I feel like they feel listened to and heard when we’re addressing all of the things that they’re bringing up to us. And it does seem like it makes them feel more empowered to use some of the other strategies too.

In addition to greater buy-in for the program, participants shared that teaching and coaching in strategies to address behavior and regulation increased caregivers’ knowledge and confidence in these domains.

I also think that once there’s empowerment around how do I respond in this moment where I feel lost and I feel like my kid isn’t able to communicate and I feel like my kid’s emotions are just too big in this moment, I think that there’s also empowerment that comes with that.

Finally, clinicians and trainers shared that embedding strategies to support regulation and behavior could have a positive impact on child social communication outcomes. Specifically, participants noted that children became more regulated within their sessions and that this change made it easier for caregivers to learn and use the Project ImPACT strategies aimed at supporting social communication development.

I think when you do address the behaviors it can lead to much better outcomes because it makes playtime more effective, more fun for the child when they’re able to fully participate. I’m thinking of one child I had who the first couple sessions he was just screaming because he didn’t have another way to communicate that it wasn’t fun for him. But as soon as we talked about a more effective way to ask for what he needed, it made playtime easier and then he ended up having really great social communication outcomes because then mom was able to more effectively follow his lead and use all the other strategies that we talked about.

Training on addressing disruptive behavior within Project ImPACT training

Project ImPACT trainers and certified coaches clearly indicated that while Project ImPACT now has supplemental modules and materials covering positive behavior supports, there is not yet guidance on how and when to effectively integrate these concepts into the program for community practitioners. Participating trainers noted that questions related to behavior and regulation support were common within community training and ongoing consultation. However, they also consistently shared that a community providers’ clinical background and experience impacted the extent to which additional guidance was needed.

So, I think folks who are trained in it and know it well, you almost don’t need it to be that explicit. But I think for folks who have strengths in other areas but might struggle with supporting the behavior, it’d be really helpful for them to have a broader understanding of how those impact strategies help to set the session up for success.

Given the frequency of questions related to navigating regulation and behavior challenges, participants emphasized the need for clearly specified decision points around addressing behavior and regulation within the context of Project ImPACT.

Discussion

The present study examined the impact of disruptive behavior in the implementation of Project ImPACT within an outpatient clinic. Quantitative results indicate that clinicians report adapting Project ImPACT to address disruptive behavior for about one-third of participating children. Qualitative interviews demonstrated that clinicians address disruptive behaviors in response to caregiver priorities or the intensity of the behavior and do so through the pacing of Project ImPACT strategies, through informal discussion and coaching on positive behavior supports, and through the formal use of positive behavior support modules embedded within Project ImPACT. Adaptations to Project ImPACT to address disruptive behaviors were associated with other adaptations to Project ImPACT, including repeating intervention content and shortening sessions. However, the frequency of behavior adaptations did not impact child social communication skill gains and clinicians and trainers perceived that these types of adaptations could increase caregiver buy-in and, at times, make the delivery of Project ImPACT more effective. Clinicians discussed that decision points around disruptive behaviors are not explicitly noted within the Project ImPACT training materials despite being a common priority of caregivers and community clinicians.

Findings from the current study have several implications. First, clinicians described a range of approaches to addressing behavior and regulation in sessions, including formal teaching and coaching, informal discussion of positive behavior supports, and the pacing of developmental and naturalistic behavioral strategies. Clinicians reported feeling that the flexibility of their approach was important as not all children require positive behavior support or to the same degree. Although research has begun to examine sequencing NDBIs so that they are followed by positive behavior interventions (Hampton et al., 2022), the results of the current study suggest the importance of considering how to support the adaptation of NDBIs to more flexibly apply positive behavior supports. This could include the incorporation of clinical and shared decision-making tools that focus on factors that clinicians reported weighing (e.g. caregiver priorities, intensity, and interference of behavior) when deciding when and how to address disruptive behaviors and dysregulation.

Although the EMR adaptation tracking and interview questions were specific to disruptive behaviors, the theme of supporting emotion regulation emerged as an important consideration. Clinicians indicated that support for child emotion regulation is embedded within Project ImPACT’s core strategies, for example, through supporting caregiver-child attunement and caregivers’ use of their own affect to support their child’s regulation. However, many clinicians shared that the connections between core social communication strategies and emotion regulation are not explicitly discussed within intervention materials. The finding that regulation is implied in Project ImPACT, but not explicitly stated, is consistent with a recent review indicating that almost no studies of caregiver-mediated interventions for young children with autism, including NDBIs, have measured emotion regulation as an outcome (Hendrix et al., 2022). Results suggest that these connections could be made more explicit and also measured within NDBI research.

The present study found no significant differences in social engagement and communication outcomes based on whether the program was adapted to address disruptive behaviors. This may indicate that children who require a range of positive behavior supports are able to benefit from Project ImPACT. However, the current study did not formally assess for disruptive behaviors or dysregulation. Thus, it is unknown whether the use of formal or informal positive behavior supports increased a child’s regulation and or reduced disruptive behavior while participating in Project ImPACT, or whether the presence or changes in these behaviors moderated social communication outcomes. Fulton et al. (2014) showed that following participation in a clinician-delivered NDBI, autistic preschoolers showed fewer disruptive behaviors. Future research is needed that examines the impact of NDBIs on disruptive behaviors and regulation while also carefully documenting the use of formal and informal positive behavior and regulation supports. Findings from this research could help to tease apart these relationships and inform decision supports around when and how to address disruptive behaviors and regulation within NDBIs.

Finally, we sought to understand trainers’ and clinicians’ perceptions of how training in disruptive behavior is embedded within the current Project ImPACT training model. Qualitative findings suggested that while positive behavior modules provide some guidance in how to approach disruptive behaviors in a formal way, newly trained clinicians often require additional guidance in decision-making around when and how to implement these modules or other behavioral supports. These findings should be considered alongside the descriptions that clinicians draw upon prior experience and implicit understandings of the relations between Project ImPACT strategies, communication, regulation, and disruptive behavior when supporting regulation and positive behavior within sessions. Thus, it may be important to consider training materials and methods that are tailored to clinician experience in these areas, with more explicit support available to clinicians in how to approach disruptive behavior and regulation more flexibly within the session.

Implications for research and practice

Findings from the current study indicate several areas of future research. First, as noted above, the results of the present study suggest the need for more explicit approaches to training clinicians in the flexible application of Project ImPACT strategies. Further, while the present study incorporated the perspectives of Project ImPACT coaches and trainers, assessing the practices and perspectives of clinicians working in non-autism-specific community settings will be important. Findings from expert coaches indicate that they may be drawing from prior experience and training to support regulation and address behavior. Thus, it may be important to understand whether more comprehensive training on topics like emotion regulation and behavioral principles is needed to support coaches with varied clinical backgrounds.

Similarly, training and supervision of new coaches should include explicit discussion of the relationship between core strategies of Project ImPACT and children’s regulatory skills. Core strategies of Project ImPACT such as engaging in child-led play and offering descriptive non-directive language are foundational elements of multiple developmental interventions aimed at supporting caregiver–child relationships, disruptive behaviors, and emotion regulation for young autistic children (e.g. Dababnah et al., 2019) and outside the context of autism (Bernard et al., 2012; Funderburk & Eyberg, 2011; Hemmeter et al., 2021). Despite the evidence base supporting the use of these strategies to address regulation and behavior and their prevalence within NDBIs, they are often not discussed within this framework in training or materials. Thus, using Project ImPACT’s developmental strategies, such as regulating affect and following a child’s lead may be useful in addressing child regulation, given the evidence base supporting the use of these strategies in other interventions (Funderburk & Eyberg, 2011). An explicit connection between existing Project ImPACT strategies and regulation and instruction in applying them in this context may support new clinicians in making these connections for caregivers during coaching. However, additional research is needed to tease apart the overlap between emotional dysregulation and disruptive behaviors among autistic children in presentation, conception, and best practice strategies.

Previous research exploring the integration of positive behavior supports within NDBIs has done so through the delivery of NDBI strategies and positive behavior supports as discrete interventions to study the effects of ordering these specific modules (Hampton et al., 2022). However, in addition to the use of formal modules, the present study suggests that clinicians are flexibly incorporating a variety of strategies to address disruptive behavior and to support child regulation and that these approaches do not negatively affect child social communication outcomes. Future studies are needed that use observational data to characterize the presence of disruptive behaviors and dysregulation more explicitly, and the variety of strategies that clinicians employ to support children and families in these areas.

Results from this study also highlight key factors weighed by clinicians when deciding when and how to support a child’s regulation and behavior within a caregiver-mediated NDBI. These decision points were consistent across clinicians and could support the use of adaptive study designs that evaluate the effectiveness of varied therapeutic strategies based on key child characteristics and caregiver priorities around disruptive behavior within NDBI. Adaptive study designs are important to explore given that not all autistic children experience emotion dysregulation or disruptive behaviors and not all families may prioritize these areas. Thus, a personalized approach to supporting children and families is warranted. Alternative study designs could also explore the relative impact of shared decision-making tools that facilitate dialogue between clinicians and families around when and how to deliver additional support for emotion regulation and behavior within NDBI.

Limitations

Although the present study presents important information on clinicians’ natural incorporation of positive behavior and regulation supports within an NDBI, there are several limitations to consider. First, the outpatient practice setting is embedded within a specialized autism clinic. Thus, the clinical decision-making that occurs within this setting may not reflect the resources and autism-specific training level typical of most community agencies. Furthermore, the population served within this clinic was on average 30 months of age, an age group for whom some level of disruptive behavior is developmentally appropriate. There may also be important differences between groups of children who required more adaptations for behavior, such as additional service received outside of Project ImPACT, which was not measured within the current study. If true, the receipt of additional services could drive our finding that social communication outcomes did not differ based on a number of behavior adaptations. Lists of current services were systematically collected within standard clinical care; however, information regarding number of hours received each week was not, limiting our ability to explore these possible relations in this study.

In addition, the qualitative information describing each behavior adaptation within the EMR was somewhat limited, and the present study includes only clinician-reported adaptations and qualitative interviews with no observational coding of sessions to triangulate clinicians’ report of these adaptations. Regarding qualitative data collection, while interviewing trainers gave us perspectives from experts in Project ImPACT and provided both coach and trainer experiences, the results reported do not capture the firsthand perspectives of community providers when attempting to address disruptive behaviors and regulation. Finally, the present study focused only on the implementation of Project ImPACT. While NDBIs overlap considerably in their core strategies, other models should be explored to assess whether outcomes and clinician experiences are similar.

Conclusion

Evidence increasingly indicates that disruptive behaviors are highly prevalent among autistic children. As NDBIs are implemented more widely across community and research settings, there is a pressing need to ensure a wide range of providers with diverse experiences are prepared to support the needs of autistic children within this framework. The present study brings us closer to understanding how clinicians currently support regulation and address disruptive behaviors within NDBI sessions. Findings suggest that the need to address disruptive behaviors and regulation is common but not universal. Furthermore, when implemented by experienced clinicians, children’s outcomes do not vary as a product of adaptations made to support regulation and address disruptive behavior. Future implementation trials are needed to test the feasibility and effectiveness of integrating shared decision support tools that guide clinicians and families on how to address dysregulation and disruptive behaviors within NDBIs.

Supplemental Material

sj-docx-1-aut-10.1177_13623613231203308 – Supplemental material for Addressing disruptive behaviors within naturalistic developmental behavioral interventions: Clinical decision-making, intervention outcomes, and implications for practice

Supplemental material, sj-docx-1-aut-10.1177_13623613231203308 for Addressing disruptive behaviors within naturalistic developmental behavioral interventions: Clinical decision-making, intervention outcomes, and implications for practice by Elizabeth H Kushner, Nicole Hendrix, Nailah Islam and Katherine Pickard in Autism

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

ORCID iDs

Elizabeth H Kushner

Katherine Pickard

Notes

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