| Summary: | AbstractAimsMethodsResultsConclusionsThis study examined engagement during one-on-one motor program sessions for children with moderate and high support needs (MHS) autism by: (1) systematically coding child behaviors as on-task or off-task, and (2) exploring therapist-reported strategies to facilitate engagement.Nine children (4–10 years) with MHS autism participated in a 13 week, twice-weekly motor program. All sessions were video recorded. A bespoke observational coding system was developed to measure gross motor skill practice, achieving interrater reliability (ICC = 0.927). A stratified sample of 27 sessions was coded. Eleven exercise physiologists completed semi-structured interviews at two timepoints, analyzed using reflexive thematic analysis.Children spent an average of 29.6% of session time in motor skill practice. Off-task periods involved sensory-seeking, co-regulation, avoidance, and exploratory or social behaviors. Interview analysis identified one overarching theme—<italic>attuning to the child</italic>—with subthemes describing the importance of the therapeutic relationship and prioritizing the child’s needs. Sessions were adapted according to each child’s cues, communication style, and regulatory needs.Findings highlight the central role of relational and regulatory processes in supporting engagement for children with MHS autism and emphasize the need for further research on mechanisms of change and therapists’ moment-to-moment decision-making.
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