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Table 2 Design requirements (in bolded rows), contributing themes and interview codes. Codes are ordered by frequency of caregiver reports within each category, frequency of reporting and final Kappa inter-rater reliability are also shown

From: Understanding the psycho-social context for a new early intervention for resistance to change that aims to strike a beneficial balance between structure and flexibility

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