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.

Ultimate Guide to PLAY DOUGH MATS

Play dough mats

After reading below about the benefits of playing with play dough mats, go grab some of them for FREE. When using these fun play dough mats, you will start helping children work on important developmental skills. In addition to all the fun children will have while using these mats (which is a win), they will be developing the necessary fine motor hand skills needed for everyday functional tasks such as; fastener manipulation, classroom tool use, grasp patterns, and overall dexterity/manipulation used in multiple fine motor tasks. Be sure to check out our resource on playdough activities for fine motor skills to support this area.

Play dough mats

The benefits of using play dough mats

Play dough is an AWESOME tool in itself!  We know that in itself, there are so many benefits of play dough in building skills in kids.

With all of the attractive colors, and the sensory feel of it, playdough can be very enticing to children. With a little preparation and care, play dough mats can be almost mess-free! If pieces fall off, just tap with another blob of dough, and it blends back in with little need for clean-up. (Just avoid the carpet!) While engaging with these super fun play dough mats, children can stay occupied for a lengthy time in either independent play, or cooperative play with a partner.  

You can easily use play dough mats during an OT session, as part of a home program, or as a fine motor station in the classroom. Each mat provides a theme to compliment any learning or skill building you might be looking for. After you read about all of the benefits, you’ll want to get all of these mats and start right away, but first let’s look at those specific skills they help develop. 

Play dough can easily be made or purchased, and used with play dough mats to focus on developing so many skills.

Many Benefits of play dough mats:

  • Hand and finger strengthening skills – squeeze, press, poke, and pinch the play dough while manipulating. Hand strength is a skill needed for most functional tasks. This helps build intrinsic hand musculature, and improves fine motor endurance.
  • Grasp skills – Tools such as plastic knives, scissors, cookie cutters, pizza cutters, and rolling pins, provide the opportunity to work on varied grasp patterns.
  • Bilateral integration skills – use both hands together in a coordinated manner to manipulate the play dough, therefore building bilateral coordination. They adjust the dough’s size, shape, and weight as needed for mat play. Bilateral coordination skills are needed for functional tasks like writing, dressing, cooking, and essentially all functional participation.
  • Manual dexterity skills – manipulate the putty to shape and pinch the dough to match the theme the of each mat. This gives them the opportunity to develop precise finger movements and thumb opposition.
  • Self-regulation skills – When children squeeze, press, poke, pinch and roll out the dough, they get deep proprioceptive input, which can be soothing and calming to a child. As an added benefit, these emotions play dough mats support the social learning and identifying emotions names to help with emotional self regulation.
  • Eye-hand coordination skills – While creating and placing the shapes on the play dough mats to match the theme, learners are coordinating their hand and eye movements, working on important visual motor coordination skills. Eye hand coordination skills can impact functional participation.
  • Gross motor skills – Engaging with play dough works the larger muscles of the upper extremity (shoulder and arm) in order to push, pull, press, and roll the dough. Don’t forget, development occurs proximally to distally, so those larger muscles need engagement!
  • Creativity and play skills – Learners use their play dough creativity and imagination to add their own details to the mats, with their own play dough creations.  They can add small beads, sequins, buttons, or pegs in addition to their playdough shapes. 
  • Social skills – If mats are used with a partner, children will have the opportunity for cooperative and collaborative play They will be learning self-control and communication, coupled with pretend play, as they work to build items together on a single mat, or by trading mats and sharing details. These would make a great tool for social skill groups!
  • Visual perceptual skills – Play dough mats work on visual figure ground skills, as learners visually scan the boards to locate the circles for play dough ball size, location, and placement. Visual discrimination skills are needed to identify any size differences in the circles, and make the play dough balls larger or smaller as indicated. 
  • Olfactory skills – Adding a little scent, such as an essential oil to the play dough will provide children some olfactory input, making the experience more multi-sensory. 
  • Tactile skills – The addition of a little glitter, rice, or sand to the play dough, will provide children further tactile input. For some learners with tactile aversion, working with playdough may be difficult at first.

Play dough does not need to be store bought. Go to our link here for some of the Best Dough Recipes.

how to use play dough mats

How to Use Play Dough Mats

Using play dough mats is pretty self explanatory. Kids love using the fun and engaging play activities and often times don’t realize they are developing skills at the same time. These steps will help with using your play dough mats in therapy, the classroom for a fine motor brain break, or in the home for a play activity:

1. You’ll need to print off the play dough mat that works for your needs. You can find different printable playdough mats for different themes.

2. Laminate the page, or slide it into a page protector sheet.

2. Select play dough, either home made or store bought. Select play dough consistency and resistance based on the individual’s needs.

3. Consider how to adapt the activity based on the needs of the individual. Some considerations include thinking about fine motor skills, bilateral coordination needs, visual motor needs, or sensory needs.

4. Position play dough mats and play dough to meet the needs and areas of development for the individual.

5. Work on opening and closing the play dough container if this is an area of concern (it’s a great functional activity!)

how to use play dough mats for occupational therapy

Adapting Play Dough Mats

Play dough mats can be used in occupational therapy to develop skills and work on goal areas through play. They can also be used to support needs and integrate adaptations in play for practice.

Play dough mats are a fun way to play and build skills at home, too. They can be used in the classroom for a brain break, a sensory break, or a tool to build fine motor skills with a classroom theme.

How can you adapt playdough mats for specific skill adaptations in OT sessions? There are so many ways…

Motor Skill Needs- For individuals struggling with motor skills, you can tape the page protector sheet to the table surface. Another idea is to use sticky tack on the back of the page protector. This can secure the play dough mat to the table and limit it’s movement during play.

Another motor skill strategy is to use a play dough mat with larger areas or smaller areas for the play dough. This can require more or less small motor movements, and can offer more or less opportunities for precision work.

Bilateral coordination needs- Encourage bilateral coordination by asking the user to hold the play dough mat on the table. This is a great way to encourage paper positioning during writing tasks, too.

Sensory needs- Play dough consistency will provide a varied tactile experience such as, sticky, slippery, firm, and partially dry. Much like different grades of thera-putty, different play dough recipes can be used to build fine motor skills or offer more or less heavy work through the hands.

Some play dough to meet tactile preferences and tactile challenges include:

Some play dough to meet tactile preferences and tactile challenges include:

Regulation needs- Building on the sensory aspect, you can offer movement-based heavy work through the hands and upper body by offering less resistant play dough (more of a silky and fluid feel to the play dough consistency) or you can offer more heavy work using a heavier grade to the resistance.

Visual needs- For users with visual processing needs, there are ways to adapt the play dough mats. Try outlining the areas where play dough is placed for a darker visual cue by using a dark marker. You can then slide the sheet into a sheet protector and play from there.

Core strength/Stability/Visual Gaze- For some, maintaining an upright posture is difficult. You can easily position play dough mats on a slant board, easel, or vertical surface using sticky tack, tape, magnets, etc. This positioning strategy can be used to either support positioning and visual gaze needs to to challenge these areas to reach a “just right” level in therapy sessions.

Free Printable Play Dough Mats

Each of the free play dough mats below can be printed off and used over and over again. A few tips for using play dough mats in therapy or in the home or classroom:

Space Play Dough Mat | gives learners the opportunity to strengthen their hands while developing essential skills that are needed for pencil writing, as well as the dexterity and precision skills that are needed for many daily, fine motor tasks. The simple thing about this outer space mat, is that it works on a specific set of muscles in the hand. 

Astronaut Play Dough Mat | can be used as part of space theme, or a solo activity. Ask your learner to pull off a small piece of play dough and roll it between the fingers and thumb of one hand. It’s important to use just that one hand as it’s part of the challenge! Doing this hand activity will help build hand strength, dexterity, coordination, and endurance of the smaller muscles of the hand and fingers. 

Play Dough City | complements any geography lesson as children fill in the circles of the city sky, while helping them to build their fine motor skills and endurance, which are needed for tasks like writing/coloring, pencil control for forming letters, functional pencil grasp, manipulation of clothing fasteners, opening/closing containers, and so much more. This cute mat can be used along with any other city activities including books, travel, and anything about city life.

Ice Cream Play Dough Mat | create small balls of play dough that fit on ice cream images, while working on hand strength and other motoric skills needed for pencil grasp, endurance for coloring, accuracy with scissors, and dexterity for manipulation of buttons, zippers, and coins. This mat can be a great take home mat for use over the summer break. Be sure to include instructions on what you want the child to do!

Toy Theme Play Dough Mat | helps children use their fingertip and thumb to roll a small ball of play dough, placing and pressing the dough onto the circles on the mat. They need just a small piece of dough to make the ball small enough to fit into the circles. This is a great activity for developing and defining the arches of the hand, strengthening the intrinsic musculature, and boosting visual perceptual skills too! This toy theme mat builds on the fundamental “job” that kids have, which is play! Use this themed mat during down time, or a rainy day, to add a little productive playtime.

Play Dough Bird Mat | gives kiddos a hand workout, while they create small balls of dough rolled with their fingers, to match the circle sizes on the mat. There are various sizes to challenge the child’s precision and dexterity. Children can count the birds and match the colors of the birds too.  Another way to use this mat is to write numbers or letters in the circles in random order and then have the child scan the mat to challenge their visual perceptual skills.

Roll and Write Play Dough Mat Bundle | all about helping kids warm-up their hands prior to handwriting. It makes handwriting more fun when using one of these 7 themed play dough mats. Children warm-up using dough, then work on letter formation, words, and sentences. 

These printable play dough mats include a themed play dough area plus a writing area. Use the play dough as a fine motor warm up and then move to the handwriting aspect.

Numbers 1-20 Sky/Ground Play Mats | helps children to work on 1-20 number formation, provides sensory input, encourages motor planning, and spatial relations. 

A-Z Sky/Ground Play Mats | work on upper case and lower case A-Z letter formation, provides sensory input, encourages motor planning, and spatial relations. 

Intrinsic Muscle Strengthening Play Dough Mat– This simple play dough mat limits the visual background and offers different sizes of circles. Users can create small balls of play dough to build intrinsic hand strength.

All of the free play dough mats are available in our Member’s Club. There, you can just click and download the play dough mats!

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.

Level 1 members gain instant access to all of the downloads available on the site, without enter your email each time PLUS exclusive new resources each month.

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A final note on play dough mats:

Do you want to use any of the play dough mats multiple times? Simply laminate them, or place in a sheet protector so children can use them repeatedly, any time they want. Play dough mats are a fun and engaging way for young children to work on problem-solving, pretend play, pre-academic skills, and other developmental functions. They don’t even know they are doing it, as they are having so much FUN!

Regina Allen

Regina Parsons-Allen is a school-based certified occupational therapy assistant. She has a pediatrics practice area of emphasis from the NBCOT. She graduated from the OTA program at Caldwell Community College and Technical Institute in Hudson, North Carolina with an A.A.S degree in occupational therapy assistant. She has been practicing occupational therapy in the same school district for 20 years. She loves her children, husband, OT, working with children and teaching Sunday school. She is passionate about engaging, empowering, and enabling children to reach their maximum potential in ALL of their occupations as well assuring them that God loves them!

Note: Only use play dough with the appropriate aged children. take sensible precautions with small or differently abled children, as play dough and small manipulatives can be a choking hazard. Adult supervision should be provided.