Managing Resistance in Therapy

client resistance in therapy

So often, we see a child of therapy evaluation and find a need for therapy intervention, but that’s where the resistance begins. Here we are talking how to manage resistance in therapy, and not only that; but how to engage with kids so that we get the truly motivated buy-in for engaging in occupational therapy interventions

Address client resistance in therapy

Resistance in therapy

If you’ve worked in OT for even a short time, you have probably experienced resistance from your clients. There are many reasons for barriers to participation in occupational therapy intervention. From differing perceptions to the outcomes of OT interventions, to not understanding what occupational therapy is and what it can do for the client, understanding therapy process is just one aspect of client resistance. 

There are so many different reasons why a therapy client my object therapy participation. Encouraging participation in therapy sessions and functional engagement in daily tasks can be a couple of underlying areas that we are trying to address in therapy sessions. But what’s more is that beyond client resistance, there may truly be functional occupations that are being missed or delayed as a result of resistance to therapy.

Additionally, when children are asked to participate in a therapy activity or to stop doing a preferred activity and transition to another, sometimes it is hard to get their “buy in,” but it doesn’t have to be that way.

Let’s cover various techniques to support children showing resistance in therapy sessions. We’ll also cover how to support follow transitions and make engaging in therapy fun through meaningful games and some simple resources to utilize to make sure therapy activities happen smoothly throughout the therapy session. 

Why do clients show resistance in therapy?

Before we get into strategies to encourage functional participation, let’s break down why we may see failure to participate during therapy sessions.

Therapy makes the client look and feel “different” than everyone else- Going to a therapy session is not something that every child or teen does, so attending therapy can be a reason that makes them look different. This can lead to resistance to participate and a feeling of dread when it comes time for therapy sessions. 

Especially for our middle school students receiving OT services, and for individuals who are very much aware that they are doing something that not everyone else is, this can be a big deal.

Don’t understand occupational therapy- Many times, we as therapy professionals are ready to evaluate or treat a resistant client and the individual states something like, “why are you here?” or “what is occupational therapy” or “who are you and why are you asking me these questions?”!

Do any of these questions sound familiar? Many times clients/patients/students are referred to occupational therapy evaluations without knowledge. This is the case in hospital or clinical situations when OT orders are part of the inpatient process. In the school based scenario, a student is referred to occupational therapy by the IEP team or a child’s parent.

Many times, the individual has no idea they are going to be seen by OT. This can lead to refusal and a resistance to participate. Whether you are working with a child in the classroom setting in a push in model or pulling a child out of the classroom, this can be a reason that resistance to participate in therapy occurs. 

Therapy is hard- Therapy tasks aren’t always easy, especially if your child is participating in an activity that they love doing. If asked to step away from an activity before they are done, they may become upset and non compliant. This can be true with the child working on handwriting tasks or working on strengthening. It is HARD to write and copy all of those sentences. It requires a lot of concentrated effort doing something difficult.

The same is true for strengthening tasks that require engagement and consistent use of muscle groups. It’s easier to regress to that comfortable and “easy” positioning. As an adult, if you are working on a project on your computer, how much advance notice would you like before you have to finish what you are working on and move to a new activity?

Therapy is a change from the normal day to day activities- Even if the typical day to day functions is something that is being worked on, including participation and functional performance, it can be a change from the “norm” to engage in therapy sessions.

Would you appreciate your coworker walking in while you are typing mid sentence, closing your laptop lid, taking you by the hand stating “it is time for the staff meeting. Let’s go!”

Or would you rather they say “just letting you know that you have five minutes before the staff meeting, see you there!”

My guess is that you would like to have some advanced notice before you have to stop working. This is the same for a child who is playing. When they are actively engaged in an activity, they have a plan and don’t appreciate being interrupted in the middle of it. This could be anything from playing with play dough, to completing a puzzle or pretend play. 

Therapy challenges the unexpected- Sometimes when kids or teens participate in therapy sessions, they don’t know what to expect. They know that they are working on specific skills, but what if that skill of task is so new and novel that the fear of the unknown exists.

This can be particularly true with things such as toileting. For the child with interoceptive sensory considerations, they may have no idea how a bowel movement on the toilet feels.

This fear of the unknown can be a real area of resistance. 

Clients Resist certain parts of therapy

What if children don’t want to stop what they are doing and resists participation in some therapy activities?

You have probably seen this in action when a child LOVES a specific therapy game or activity. It might be that they love anything to do with a therapy swing. But what might really be happening is that the child is overly focused on that item because it’s been a cause for positive feedback in the past.

Or maybe, if the item is a sensory activity like a sensory swing, that the child receives the sensory input that they crave.

Or, perhaps the preferred activity is a highly motivating activity because it’s a theme or character that the child really loves. In these cases it can be very difficult to move from the preferred activity to a non-preferred activity. 

In many cases, the child even becomes overstimulated or dysregulated as a result of focusing on that one particular activity, or as a result of reciting too much stimulation or a certain type of sensory input from that one activity. 

When a child feels like they don’t want to transition to a new activity or that they didn’t have enough time to finish the task they were completing, they may become upset and hard to calm down. 

In these cases, using a positive redirection activity that will give children the ability to comfort themselves and they are feeling overwhelmed.

 Giving them time and space to calm down is very important, especially in a non-threatening way. If the child is upset, part of the therapeutic process is to support the child to calm down, identifying feelings and emotions, and offering support. Therapy professionals can guide them through communicating how they are feeling and participating in solving the problem at hand. 

How to engage the child that resists therapy sessions

Whether you are working in a clinic, hospital setting, or school-based, resistance to therapy happens. When giving instructions and laying out transition expectations to young children, it is important to keep in mind their individual and collective developmental age range in order to give clear and concise directions.

The following are strategies to engage the child or teen showing resistance in therapy. 

This can include components of getting buy-in that are important to include in every direction given to a young child. 

1.Clear and concise expectations- Having a plan of expectations and then using clear directions in those expected task completion is a key way to support engagement.

Use these tips to support and give clear expectations with clients:

  • When giving a statement or direction to a child, make sure that it is easy to understand.
  • Keep in mind the age of a child and their receptive language skills.
  • Using one or two step directions, children will be able to remember what is being told to them.
  • When giving the directions, make sure you are in the same room as the child (not yelling “it’s time for dinner” from the kitchen area), preferably kneeling down at their eye level.

Additionally, certain tools can support the “flow” of therapy sessions and offer a visual cue for participants with concrete expectations. Strategies that can support these expectations in therapy include:

2. Stick to Routines. When we work on daily routines, such as bedtime, clean up time, morning routines, leaving the house, etc., we use routines to make sure that the routine of events is the same every time. This strategy can carryover to therapy interventions. Using a similar routine for therapy sessions can include premeditated steps in order to allow children to feel successful and prepared for what is coming next.

Here is a great example of a therapy session routine:

  1. Arrive to therapy
  2. Check in
  3. Sit in the same spot in the waiting room
  4. Move to the therapy clinic area
  5. Hellos and talk about last session
  6. Discuss areas that the client wants to work on
  7. Warm up activities
  8. Address identified needs
  9. Preferred activity
  10. Cool down activities
  11. Discuss home program and plan for next visit

Another schedule strategy that can be used for countering resistance to participation in therapy includes staggering preferred activities with non-preferred tasks. For the child that struggles with handwriting and really is resistant to handwriting tasks, you can stagger preferred activities (while selecting options that also address underlying areas of need or other goal areas). You can come up with a treatment intervention plan that includes options for the client to select from that are both preferred and non-preferred.

This strategy can look like:

  • Arrive to therapy
  • Check-in
  • Select activities to address based on goal areas
  • Preferred activity
  • Non-preferred activity
  • Preferred activity
  • Non-preferred activity
  • Preferred activity
  • Cool down activities
  • Discuss home program and plan for next visit

One of the best ways to make transitioning from a preferred activity to a non-preferred activity is to make it FUN! When the transition process is exciting, children will join right in. 

You can find more examples of daily routines that are used for functional participation here on the website. 

3. Utilize Auditory Cues– To make sure that the child in therapy hears what you are saying, when you are giving them the directions, have them stop and look at you.

A fun way to do this with young children is to have a saying such as “1,2,3 FREEZE” where they put their finger over their lips and look at you. There are so many other fun “stop and listen” sayings and games that you can find in this video.

Games for Resistance in Therapy

Here are four games that make participating in therapy interventions fun. Use these ideas to counter resistance to therapy activities.

  1. Timer Games – Using timer games are great for making clean up time fun. These games include: “How fast can you clean up all the toys?” or “Can Charlee put all the blue blocks away faster than Henry can put all the green ones away?” When children are engaged in a game during clean up, it’s not so boring!  
  1. Movement Songs – Pairing movement and music together to get children to a specific place will make the transition very exciting. I love using songs like “We are the dinosaur marching marching” or  “Flap your arms like a butterfly to the line” or “Jump like a bunny  all the way, over to the _____.” When pairing a movement activity with a direction and melody, children learn that transitioning to the new activity location is just as fun as what they have been doing! 
  1. Jobs – Making children an active part of the next activity, but giving them a very specific job, makes them feel important and gives them purpose for moving to the next activity. For example, if you want your child to transition to nap time, they can help pick out the books that are going to be read to the children, or they can put a new pillow case on their pillow. If children are transitioning to mealtime, they can set the table, or hand the other children their name cards. There are so many different jobs that allow children to become part of the new activity.
  1. Visual Supports- When creating a routine for the classroom or at home, there are several ways to include visual supports to make transitions easier for the children and for you. Using a visual schedule will make your days so much calmer! You can create a visual schedule for different parts of your day (such as morning and bedtime routines) or for your full day. The visual schedule will help children understand what is coming next. 

Every day children are asked to transition at least 50, maybe 100 times. That is A LOT! Children don’t always have a lot of control over what is going to happen during their day, but allowing them time in between new activities, making the transition fun, and giving them a job to feel important, will make transitions feel less like a chore. As adults, if we stay consistent, giving children directions while being mindful of their developmental level, our days will become less stressful and more fun!

Colleen Beck, OTR/L is an occupational therapist with 20+ years experience, graduating from the University of Pittsburgh in 2000. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. As the creator, author, and owner of the website and its social media channels, Colleen strives to empower those serving kids of all levels and needs. Want to collaborate? Send an email to contact@theottoolbox.com.

The Power of Yet

The power of yet

Do you focus on the “power of yet” when helping kids with developing a growth mindset? A subtle mindset shift can do great things when it comes to shifting perspectives. Here, we’re covering what the power of yet means and how to help kids use this strategy in every day tasks with a printable power of yet worksheet.

The Power of Yet activities

The power of yet

When we make a decision to learn new things, we are fostering the power of yet.

When we struggle at a task but persist and keep trying, we are putting the power of yet to work.

When we look forward to doing something, we exercise hope and optimism.

All of these examples describe the power of yet!

The power of yet starts with a growth mindset. A growth mindset is “the understanding that abilities and understanding can be developed” (Mindset Works, n.d.).

Those with a growth mindset believe that they can get smarter, stronger, and more talented through putting in time and effort.

According to Susan Jerrell, founder of Time out for Teachers,

The power of yet teaches students:

  • they can learn
  • learning takes time and effort
  • results come from hard work
  • giving up isn’t an option 

the power of yet carol dweck

This way of thinking became popular through the work of Carol Dweck in her book (Amazon affiliate link) Mindset.  She teaches about the “power of yet.”

This mindset shifts the focus away from all the things one can not do, to what one can not do YET.  As therapists, the population we serve is acutely aware of all the things they can not do.  It is easy to get bogged down by shortcomings and endless goal setting. This can be discouraging, and lead to shutdown or failure.

When developing this growth mindset and encouraging the power of yet, be mindful of the four traps to success

  • People don’t set clear goals (and don’t break down goals to achieve them)
  • They feel discouraged
  • They feel overwhelmed
  • They are not ready to change

Ask yourself, is my learner ready to change?  Is this a goal I want for them, or they want for themselves?  This might also be a good question to ask of the parents.  Are THEY ready for change? 

Is it worth all your time and effort to teach your learner to fold laundry, if the parents are just going to do it themselves?  Should you problem solve and set endless goals to get your learner out of their parent’s bed, if the parents are really not ready for this change?

Young people may not care about change, or the work entailed in growing may not seem worth all of the effort.  In this case, you will need to get creative if this change is important to their growth. 

Shoe tying is a great example.  This is an important skill, however try telling that to a six year old who just loves his Crocs!  In this case, some creative goal setting, and a great incentive at the end might help nudge them along. 

Power of Yet Activities

Goal setting IS important, however it is crucial to go about it the right way, or this too will end in failure. The OT Toolbox has some great posts about Goal Setting and Goal Ladders

Check out this cute video from Sesame Street with Janelle Monae singing about this “power of yet”.  This is a great tool to share with young learners about embracing change, and being able to learn new things.   

Courtney Ackerman of Psychology Today gives the following tips to teaching the power of yet:

  • Work on your own growth mindset first. It is difficult to teach the power of yet 
  • Go beyond the “mindset jargon” and inspirational quotes to really focus on what the power of yet means
  • Praise properly, focusing on their efforts rather than shortcomings or natural talent
  • Embrace the word “yet;” use the word “yet” with children to give them a sense they can make a change
  • Take advantage of mistakes children make; be ready to praise them for their efforts but also point out any issues in their approach and brainstorm better ways to handle the situation with them
  • Let kids fail; another vital part of growth in children is to let them fail instead of showing them how to do everything or saving them from making mistakes. This is part of growth mindset mistakes.

Free Power of yet worksheet

Today’s free printable worksheet teaches learners to embrace what already makes them awesome, along with recognizing the power of yet.  I am not able to ride a unicycle YET.  I can not speak fluent Spanish YET.  I am awesome at riding a two wheeled bike, and can speak moderate Spanish.  

Harness the power of yet, set attainable goals, embrace skills along with shortcomings.  Use the power of yet printable to brainstorm goals, focus on awesomeness, and develop a plan for growth. From a treatment planning objective, this task goes beyond just introspection and planning for the future.

Use this letter to future self printable as a tool to support goal development and planning for the future and development tool to achieve goals that have not yet been achieved.

Think of the other skills that can be addressed during this activity:

  • Social/Executive Function – Following directions, turn taking, task completion, orienting to details, neatness, multi-tasking, attending to task, and impulse control
  • Handwriting- Letter formation – correctly forming the letters top to bottom.
  • Letter sizing – correctly fitting the letters into the provided space. Spacing, line placement, directionality, and spelling are also addressed
  • Fine motor skills- strengthening, hand development, and grasping pattern
  • Scissor skills- Cutting on the line ( if you choose to add this step), within half inch of lines, in the direction of lines
  • Bilateral coordination – remembering to use their “helper hand” to hold the paper while writing.  Using one hand for a dominant hand instead of switching back and forth is encouraged once a child is in grade school or demonstrates a significant strength in one or the other.
  • Strength – core strength, shoulder and wrist stability, head control, balance, and hand strength are all needed for upright sitting posture and writing tasks.
  • Social function – working together in a group, problem solving, sharing materials and space, turn taking, talking about the activity

How do I grade this Power of Yet activity?

When I use the word “grade,” I mean make it easier or harder, not give it a letter grade or score it.

  • Lowest level learners can dictate what they would like written
  • Middle level learners can write one or two words about their awesomeness and goals
  • Higher level learners can write an idea about their goals, then create a goal ladder, checklist, or graphic organizer.  This turns into a multilevel activity to use during many sessions.  
  • Talk about the the power of yet, growth mindset, setting goals, and introspection/self reflection
  • Project this page onto a smart board to work as a group
  • More or less prompting may be needed to grade the activity to make it easier or harder.
  • Make lines within the larger boxes to provide borders and boundaries to write in. Many learners struggle to write legibly in a large box

Growth mindset is interesting in that some people feel they are flawed and will forever need work, while others believe they are perfect just the way they are. Try and find that balance between the self defeated attitude and the “I am perfect” belief. We all have room to grow and new things to learn. 

A therapist I worked with for many years did not say, “practice makes perfect” as things are never perfect.  Instead she would say, “practice makes better.”  

This resource is also available inside the Member’s Club.

Want to add this resource to your therapy toolbox so you can help kids thrive? Enter your email into the form below to access this printable tool.

This resource is just one of the many tools available in The OT Toolbox Member’s Club. Each month, members get instant access to downloadable activities, handouts, worksheets, and printable tools to support development. Members can log into their dashboard and access all of our free downloads in one place. Plus, you’ll find exclusive materials and premium level materials.

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Free Power of Yet Activity

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    NOTE*The term, “learner” is used throughout this post for readability and inclusion. This information is relevant for students, patients, clients, preschoolers, kids/children of all ages and stages or whomever could benefit from these resources. The term “they” is used instead of he/she to be inclusive.

    Victoria Wood

    Victoria Wood, OTR/L has been providing Occupational Therapy treatment in pediatrics for more than 25 years. She has practiced in hospital settings (inpatient, outpatient, NICU, PICU), school systems, and outpatient clinics in several states. She has treated hundreds of children with various sensory processing dysfunction in the areas of behavior, gross/fine motor skills, social skills and self-care. Ms. Wood has also been a featured speaker at seminars, webinars, and school staff development training. She is the author of Seeing your Home and Community with Sensory Eyes.

    Separation Anxiety Activities and Tips

    separation anxiety activities

    Today, we have a couple of separation anxiety activities that can support kids who struggle with school drop off. Many times, kindergarten or preschool drop off is full of tears, especially those first few weeks of school. Here, you’ll find a great connection activity to help preschoolers and parents find a way to make preschool drop off easier by connecting through the book, Owl Babies. Use this Owl Babies activity to help with that preschool separation stage. This post shares movement based separation anxiety activities that can help kids who are experiencing separation anxiety in preschool drop off, with ideas based on the children’s book.

    Separation Anxiety in Preschool or Kindergarten

    Step into a preschool classroom on the first day of school and you will likely see a few tears here an there (possibly some of those tears coming from the parents dropping off their child for the first time!).

    Separation anxiety in preschool age is normal! But here’s what you need to know about that visible preschool behavior that may be fueled by something besides getting used to leaving mom/dad/caregiver for the first time…and how to help with a simple preschool self-regulation strategy.

    The movement-based, sensory activity we share below can actually be used with preschool through kindergarten:

    • the 3 year old preschooler who is just being dropped off for the first time
    • the 4 year old preschool student
    • pre-k kids
    • kindergarten students
    • older, grade school students who are sad or upset on the first day of school

    preschool anxiety

    So, what is happening with preschool anxiety that causes tears, meltdowns, and clinging to mom or dad at the day care or preschool drop off?

    You have probably seen it before:

    Every Monday, Wednesday, and Friday, it’s time for preschool. The routine at home is the same: excitement, packing the bag, and gearing up for a day of learning colors, songs, preschool activities, and nursery rhymes. Getting into the car and driving to preschool is no problem.

    But then you pull into the parking lot and the worries begin.

    Tears, crying, clinging to Mom, negotiations, promises of seeing the little one in just 2 short hours.

    Two minutes later, she is happy, playing with play dough, and dry of all nose drips.

    It might even seem as if the preschool separation meltdown is just part of the morning routine.

    As a momma of four, I’ve seen plenty of tear-filled drop-offs.  

    And it just never stops breaking your heart.

    Separation anxiety is actually considered a normal process that occurs in early childhood, as a result of a maturing physical, cognitive, and emotional development. Specifically, the areas of development that lead to a period of separation anxiety in young children include:

    • Visual processing system (visual memory, visual closure)
    • Executive functioning skills (working memory)
    • Self-regulation skills (connecting emotions with behaviors)
    • Social-emotional maturation (emotional connections, attachment, and feeling safe with certain individuals)

    Despite the normal development that results in fears, worries, or flat out meltdowns following or leading up to a period of separation, severe separation anxieties do have the potential to negatively impact a child’s social and emotional functioning and this is especially true when the young child then avoids certain places, activities, and experiences that are necessary for healthy development.

    Separation Anxiety Disorder

    Sometimes, the family, parents, or caregivers also avoid these places, experiences, and activities. This can lead to even more negative experiences. When the family supports avoiding certain places or situations because of the young child’s separation, we can have situations where separation anxiety “hangs around” longer than is part of typical development.

    Officially, Separation Anxiety Disorder (SAD) is defined as “developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached” (American Psychiatric Association, 2000). However, for the young child, separation angst does not mean a disorder is present. It is only when the anxiety levels are so severe that they are not appropriate for developmental age that the official diagnosis of Separation Anxiety Disorder should be investigated.

    For those with severe symptoms, Separation Anxiety Disorder may result in school refusal and a disruption in educational attainment, refusal to attend doctor’s appointments, dentist visits, or other situations where a child is separated, no matter the physical distance, from the parent or caregiver.

    What causes Separation Anxiety Disorder?

    There are many developmental areas that enable to progression of separation anxiety in toddlers and preschoolers from levels of worry and age-appropriate anxiety at separation to an inefficient and “disorder” level of worry.

    Studies show us that some of these considerations may include:

    • Parenting behavior
    • Low parental warmth
    • Poor attachment
    • Trauma to the parent during the baby’s young years (death in the family, environmental, or other big situation)
    • Trauma to the child (Adverse childhood experiences, both large and small)
    • Insecure or anxious attachment styles
    • Diminished sense of control over one’s environment
    • Overprotective and over involved parenting behaviors
    • Parental intrusiveness- including extreme decision making on the part of the parent
    • Parental intrusiveness- including providing excessive assistance in the child’s daily activities (beyond age-appropriate ability)

    Common signs of separation anxiety in kids

    The natural and developmental stage of separation anxiety occurs from around age 6 months when the baby is able to notice that something is missing from their field of vision. This skill requires development of several areas:

    • Visual perception
    • Attention
    • Working memory (executive function)
    • Sensory motor

    Separation anxiety typically continues from around 6 months of age to about 5 years of age, however signs of separation anxiety can persist after age 5 and through age 6.

    However, the cognitive and emotional development that occurs during this age allows for kindergarten and younger elementary aged individuals to separate from their loved ones and know that they will be there even when the are not in view.

    Once the underlying areas noted above develop (around 6 months of age), you may see some common signs of separation anxiety:

    • Crying when the parent leaves the room or home
    • Upset and crying when a babysitter or caregiver comes into view
    • Tantrums
    • Avoidance behaviors (refusing to participate in activities that require separation)
    • Clinging to parents
    • Refuse to attend certain situations
    • Apprehension about harm coming to parents
    • Fears the parent will leave and not return
    • Running from the classroom/school bus/appointment setting

    Today, I’m sharing a simple trick for helping kids with separation anxiety at preschool or other drop-off situations like our weekly church nursery adventure.

    Separation anxiety activities

    separation anxiety activities



    This post contains affiliate links.

    Social Stories- Use social stories to create a visual narrative about how drop offs go and that parents will be back to get the child. Social stories can offer a verbal narrative for the child to use during these situations. Some of our social stories include:

    Self-Regulation Strategies- Practice the regulation tools that support the individual’s emotional status with self-regulation strategies. Select a set of calming or heavy work strategies that can be used in preparation for the separation situation, whether that be using at the school bus stop (like this deep breathing school bus exercise) or while driving into school. Having those set of strategies readily available and discussing how the child feels will go a long way.

    Movement-based separation activity – One fun way to work on separation anxiety in preschoolers that becomes part of the routine…here we are talking about the preschooler or kindergarten aged child that cries, clings to Mom or Dad, but then warms up to the classroom activities.

    Practice routines- Do the same thing every day during the week in preparation for school, including bed times, morning routines, and transportation routines. These visual schedules can help with some individuals.

    Wearable Charm- Another similar strategy is to create a DIY separation anxiety charm. Kids can make this along with the family adding heavy work through the hands. then, wear the charm to know that parents and caregivers still love and miss them even when not in view.

    Get enough sleep– Practicing good sleep hygiene is important for the child as well as the parent or caregiver. This has an impact on behavioral response and self-regulation.

    Books about Separation- The activity listed below uses the book Owl Babies. But we added a heavy work goodbye sign that parents and children can use at school drop offs to ease separation anxiety. Or, this activity could work for kids that struggle with the transition to the classroom, because they are missing Mom and Dad or other caregiver.

    Use the book, Owl Babies by Martin Waddell!

    Owl Babies Activity

    We read the book, Owl Babies  and fell in love.  

    The sweet little Owl Babies in the book wake up from a nap to find their mother gone from the nest.  The owl siblings go through a series of concerns and thoughts about where their mom might be with a little almost-tears.  

    My older kids thought the book was pretty awesome and decided that each of the owl babies in the book were one of the girls in our family.  There were a few similar personality traits that aligned with the owls in the book and the sisters in our house.  

    The idea of knowing that mom comes back when she leaves is a lesson we’re going through at Sunday School each week and one that happens so often with kids.  Just like the Owl Babies, it can be hard to stay calm and not worry when mom goes away.  

    We decided to come up with an owl themed movement activity that kids could do when they are feeling anxious after leaving mom or dad.  

    Try this trick to help with separation anxiety in preschoolers, based on the children's book, Owl Babies.


    School Drop Off Anxiety

    This activity would be perfect for preschool kids who are experiencing separation anxiety at the start of school or in a new classroom situation. For kids that cry at school drop off, or really struggle with missing Mom or Dad, this school drop off anxiety activity can help.

    To do the activity, first read Owl Babies together.  Then, talk about how the owls in the book must feel when they see their mother has gone out of the nest. Finally, talk about how when the mom or dad in your family has to go away for a little while, they always come back and that they are thinking of the little one in your home while they are gone.

    Try this trick to help with separation anxiety in preschoolers, based on the children's book, Owl Babies.


    One easy way to help with separation anxiety is to come up with a hand signal.  We decided that making a bird wing sign would be a lot like an owl in flight.  Hook your thumbs together and spread your fingers out to create the wings of an owl.

    Then, wrap both hands around your thumbs to create a little owl baby of your own.  Now, squeeze your hands tight to give them a hug.  Your child can do this motion when the are feeling sad or nervous at school.  Tell them to think about the owl babies in the book and how they felt when their mom came back.

    School drop off anxiety activity for separation anxiety in students

    Squeezing the hands tightly can provide a bit of proprioceptive input that is calming in a stressful situation like the preschool drop-off.  A simple hand hug might be just the thing that can help! It’s a self regulation activity that supports the whole body as a mechanism to address emotional regulation needs that show up as crying, clinging, and bolting “behaviors”.


    Then, when you pick up your little baby, be sure to swoop them up in a big hug!


    This activity would work with preschoolers who are a little older than my two year old.  She really enjoyed the book, Owl Babies, though and we have read it again and again!


    Let me know how this tip to help with separation anxiety works with your preschooler!

    Use this separation anxiety activity to support kids that struggle at school drop off with anxiety or worries.

     

    Try this trick to help with separation anxiety in preschoolers, based on the children's book, Owl Babies.


     

    Trauma Informed Occupational Therapy

    trauma informed occupational therapy

    In this blog post, we are addressing trauma informed occupational therapy, including trauma informed interventions and how to take a trauma informed approach in occupational therapy.

    Trauma informed occupational therapy is based on the 6 principles of trauma informed care in OT interventions.

    Imagine your mental, physical, and emotional health as a backpack. Some days, that backpack may be really heavy, full, and wear you down. Other days, it may be a bit lighter, and you are quicker on your feet, but the backpack is always there. This is the visualization of health that I think is just perfect when discussing trauma-informed occupational therapy practice

    Trauma Informed Care: the hypothical backpack

    Everyone wears this hypothetical “backpack”; young and old, rich and poor. It’s up to us as health care professionals, to do our best to consider what we know about what load a person is carrying, while knowing that we won’t ever fully understand someone’s story. 

    Included in this “loaded backpack” is the connection between emotional regulation and executive functioning skills, where both emotions and the ability to self regulate, impacts cognitive actions.

    Having an awareness of this emotional health, allows one to shift perspectives on how one behaves, acts, speaks, and functions. Cognitive and emotional health can be a large factor of someone’s overall health.

    trauma informed occupational therapy

    WHAT IS TRAUMA-INFORMED PRACTICE?

    It’s important to understand the definition of trauma informed practice.

    The effects trauma and adverse childhood experiences have on a person have been understood for some time now. Infant, child, and adolescent mental health is still a growing field.

    The “backpack” visual helps to remember that even though occupational therapists may not work in a mental health setting, an individual still carries their traumatic history, anxiety, or depression as they walk into your office. 

    Trauma informed care is different than trauma-specific interventions. Where trauma informed refers to the awareness and recognition of various traumas and the impact of organizations or systems impact individuals, families, groups, communities, etc. the specific interventions address assessments, treatments, and specific recovery supports to impact trauma.

    Example of Trauma Informed occupational therapy

    Take 5-year-old ‘Thomas’ as an example. His aunt brings him to therapy at your outpatient clinic, and you notice that he is really shy and resistant to join you in a treatment room.

    Thomas was referred to OT for delayed fine motor skills, but you are unable to convince him to do much with his hands at all. He won’t even look at you for more than one second.

    After a few sessions pass, and there are no improvements in his participation, you ask the aunt how things are going at home, and learn a new perspective about Thomas’ overall health. You still must provide services for his fine motor skills, but now you do so through a new lens that respects, and includes his needs as a child with a traumatic history. 

    An individual’s traumatic history may not be the reason they are seeking services, but it should always be considered, and assess for. Traumatic experiences shape the way we perform our occupations.

    The trauma response and/or triggers should be considered in all aspects of practice; when writing treatment plans, speaking to the individual and their family, and designing the treatment environment. 

    This is trauma-informed occupational therapy practice in a nutshell.

    GUIDELINES FOR TRAUMA-INFORMED Occupational Therapy

    How will you adjust your services to meet the unique needs of an individual who has experienced trauma?

     “Given the long-term effects of adverse experiences in childhood, it is particularly important that all disciplines working in health care assess trauma; address safety in schools and the community; build strengths and resilience; and provide opportunities for educational, economic, and social successes” (AOTA, 2019).

    Evidenced-based practice is always the best place to start. The AOTA’s guidelines from the May 2019 continuing education article Understanding and Applying Trauma Informed Approaches across Occupational Therapy Settings, breaks down trauma-informed practice in occupational therapy. This resource highlights best-practice standards from the Substance Abuse and Mental Health Services Administration (SAMSHA).

    6 Trauma-informed Principles:    

    The 6 principles of trauma informed care are as follows:

    1. Safety 

    2. Trustworthiness and transparency 

    3. Peer support and mutual self-help 

    4. Collaboration and mutuality 

    5. Empowerment, voice, and choice 

    6. Cultural, historical, and gender issues.

    The table below is a modifed version of Figure 1 from the AOTA (2019) article. It provides examples of what to do and what not to do in accordance with the principles above. 

    Trauma Informed Occupational Therapy Do’s and Don’ts

    Table Adapted From Figure 1, AOTA (2019)

    Do Don’tPrinciple
    Ask permission before doing anything. Assume an individual’s comfort level.#1 Safety 
    #4 Collaboration and mutuality 
    #5 Empowerment, voice, and choice 
    Acknowledge what you cannot change Ignore things over which you cannot control#2 Trustworthiness and transparency
    Always ask preferred pronounsAssume based on appearance, etc. #6 Cultural, historical, and gender issues
    Recognize that trauma manifests in many different ways.Automatically attribute challenging behaviors to personality #1 Safety

    Becoming a trauma-informed provider is not an easy shift for everyone. Considering the current pressures that healthcare professional face, having to adapt towards trauma-informed care is not always supported by staff or administration.

    The AOTA provides resources and valuable information for occupational therapists based on the setting they work in. 

    The table above takes into consideration, the Four R’s of Trauma Informed Care: realize, recognize, respond, and resist re-traumatization.

    Four R's of trauma informed care

    Trauma Informed Strategies for Occupational Therapy

    Many of the following guidelines will assist all healthcare providers, educators, and caregivers in learning trauma-informed practices. 

    Early Childhood Settings: Increase Collaboration to Promote Prevention 

    • Promote early bonding through skin-to-skin, kangaroo care, private rooms, and opportunities for parent decision-making
    • Increase the amount of collaboration with all involved, and identify the barriers to involving family members in the care of their child
    • Celebrate family advocates
    • More ideas and resources are available at Zero to Three, The Center of Excellence for Infant and Early Childhood Mental Health Consultation, and Think Babies

    School Settings: Recognizing Common Trrauma-based Responses

    • Trauma has negative effects on learning, and should be addressed school-wide (not just for students who receive special education)
    • AOTA suggests that OTs frame school behaviors through a lens that recognizes potential triggers and responses
    • Common traumatic stress behaviors include: “intrusive thoughts, irritability, arousal, anxiety, fear, difficulty concentrating, sensory dysregulation, aggression against self and others, dissociative symptoms, somatization, and character issues” (AOTA, 2019)
    • Trauma-Sensitive Schools Training Package 
      • Online training offered by the National Center for Safe, Supportive Learning Environments. 
      • AOTA reports using this training as a Tier 1 intervention, educating the staff and ensuring common understanding. 
    • Cognitive Behavioral Intervention for Trauma in Schools (CBITS) intervention
      • Created by Wong and colleagues specifically to target children subjected to community violence
      • Suggested use as a Tier 2 or targeted intervention
    • Trauma-Focused Cognitive Behavioral Intervention (TF-CBT) 
      • Similar to the above, but suggested practice in Tier 3 intervention, including students and their families, in collaboration with community mental health providers. 

    The AOTA (2019) offers more information about occupational therapy’s role in trauma-informed care in various settings, including primary care, community, residential, and foster care settings.

    Regardless of the setting, location, or age group you may work with, trauma-informed practice is necessary.

    We hope this article gave you some insight on a very important topic, and ideas on how to incorporate trauma informed care it in your practice – wherever you are. What will you do to move towards a trauma-informed practice? 


    Sydney Thorson, OTR/L, is a new occupational therapist working in school-based therapy. Her
    background is in Human Development and Family Studies, and she is passionate about
    providing individualized and meaningful treatment for each child and their family. Sydney is also
    a children’s author and illustrator and is always working on new and exciting projects.