Initiate-manage-sustain: A multimodal conversation analytic approach to understanding therapeutic engagement for children with autism spectrum disorder

While children with Autism Spectrum Disorder (ASD) are often perceived as disengaged from social interaction, fine-grained analyses of how they are actively guided into engagement remain limited in scope. This study adopts a multimodal conversation analytic (CA) approach to examine naturally occurring interactions in specialized therapy sessions involving Mandarin-speaking children with ASD, with a focus on the multimodal practices through which therapists scaffold children's responsiveness. Drawing on video-recorded data, we identify a locally recurrent three-phase interactional structure—Initiating, Managing, and Sustaining—through which therapists systematically deploy embodied resources to organize interactional sequences in therapeutic settings. In the Initiating phase, therapists use gaze, gesture, and tactile cues to establish joint attention prior to instruction. In the Managing phase, directives are enacted through gestural modeling and co-occurring embodied actions, which make abstract instructions perceptually accessible and imitable. In the Sustaining phase, multimodal positive assessments (e.g., verbal praise, thumbs-up gestures) reinforce participation and stabilize engagement. Within this clinical context, embodied practices are not supplementary to talk but interactionally constitutive, as they scaffold verbal input and co-construct children's understanding. The findings show that effective engagement is achieved not simply by overcoming communicative challenges but through the sequential organization of multimodal resources. Our analysis suggests potential strategies for designing responsive engagement that nurtures communicative potential through flexible integration of verbal and embodied resources. These context-specific insights may inform clinical approaches that integrate language and embodiment in comparable therapeutic settings—offering empirical grounding for future theoretical and practical development. In an era of standardized protocols, this study returns us to the irreducible truth: therapy happens in the space of multimodal actions, not merely words. Therapists are thus encouraged to integrate verbal and non-verbal resources in a laminated, context-sensitive manner, attending to multimodal processing and individual communicative style, as the foundation of person-centered care.