"Let's Try to Stay on Track": Exploring Therapists' Responses to Digressive Utterances of Children with ASD

Autistic children's digressive utterances can disrupt therapeutic progress, yet remain understudied in China. This study investigates how Chinese therapists respond to such digressions during Naturalistic Intervention (NI) sessions, specifically exploring how they navigate the tension between structured therapeutic goals and spontaneous interactions while adapting evidence-based practices (EBPs) to individual child profiles and sociocultural contexts.

Applying discourse analysis (DA), we analyzed 19 NI sessions involving five Board Certified Behavior Analysts (BCBAs; ≥2 years of experience; trained in NI) and ten Chinese autistic boys (aged 29-78 months; Level 1 ASD). Therapists delivered tailored NI sessions (4-30 hours/week), embedding communication goals within play-based routines. Sessions were video-recorded in therapeutic settings.

Therapists employed seven distinct response practices spanning a directive-to-elicitory continuum. Immediate refocusing practices (restatement with nonverbal cues, digression-termination before refocusing, and integration) prioritized task adherence but risked further disengagement. Delayed refocusing practices (minimal acknowledgment before refocusing, accommodation before refocusing, and following the child's lead before refocusing) validated children's agency and elicited higher rates of goal-aligned responses. Digression-following practices fostered spontaneity but risked further divergence. Notably, accommodation and following the child's lead before refocusing elicited the most contingent responses, while abrupt termination often provoked resistance. Senior therapists employed more diverse practices while favoring delayed refocusing practices, whereas juniors favored immediate refocusing practices. Practice selection was influenced by digression sub-focus, therapist experience, child characteristics, and sociocultural contexts.

Findings reframe digressions as agentic bids necessitating mutual adaptation, aligning with "the double empathy problem". As the first DA study of therapist responses to digressions in China, this study underscores the clinical importance of culturally attuned flexibility for validating autistic agency while maintaining therapeutic progress. Based on the research findings, therapist training should emphasize reflective, context-responsive practices to enhance engagement across cultures.