When a Child Says “No”

Tips & Tactics for Encouraging Engagement in Therapy

Recently a colleague and I were asked to present at a Paediatric Special Interest Group hosted by the New South Wales Occupational Therapy Association on the topic ‘What to do with the child that says no: Tips & tactics for encouraging engagement in therapy’. It was a highly informative evening and a great chance for us to share our experiences working as part of a transdisciplinary team, alongside teachers, teachers’ aids and other therapists to provide motivating, engaging and individualised learning programs for young people with ASD.

When exploring the topic and reflecting on our experiences working at Giant Steps Sydney, we came up with five key questions that we have asked ourselves many times when dealing with children who are resistant to participating in therapy. These key questions and subsequent strategies can be tailored to be used across a variety of therapy settings such as schools, private practice, community services and hospital inpatient and outpatient services.

1. Has enough trust and rapport been built with the child for them to follow through with what you are asking them to do?

Developing a trusting relationship with the child is the most crucial and in most instances, the first step in therapy. This can be done by engaging with them in things that are interesting and important to them. Playing alongside or with them, conversing with them about their hobbies and interests, giving them time and space at the same time as setting clear boundaries.

The 1 to 5 rule

As therapists and educators we are often demanding things of children, and telling them what to do Just imagine, your boss or supervisor constantly telling you what to do. It would feel pretty stress inducing! The 1 to 5 rule outlines that for each demand given there should be five comments. These comments can be in the form of encouragement/compliments (“well done, great job”), topical (when crossing the road you could comment on the size, colours, branding of cars) and/or disguise the demand as a comment so to direct the child’s attention to the task at hand (e.g. a child needs to put their shoes on so the therapist says “Oh I love your blue shoes! Do they give your feet a big hug?”

2. Is the intervention or activity chosen relevant to the child?

A key to engaging children in therapy is ensuring that the activity is meaningful to and motivating for the child (not their parents, teachers and/or the therapist).

Interests

Try structuring therapy sessions around things that interest the child (e.g. numbers, transport, Disney, music) as this can be a great way to capture their attention. For example, making necklaces or bracelets during a fine motor activity for teenage girls; using music and song to encourage a child to brush all sections of teeth; or taking a toy car or favourite soft toy through a gross motor obstacle course. Another idea might be to structure the session so that when the child has completed a task or set of tasks, they get to partake in a motivating activity or free choice.

Edge of learning and sensory needs

Ensure that the activities are pitched at the child’s edge of learning, that means, that the therapy outcomes are challenging but attainable for the child. Additionally, meeting the sensory needs of the child within activities will help them to be in an available space for learning, whether it be including movement and proprioceptive elements for the ‘sensory seekers’ or providing ear muffs and a quiet environment for those that are sound sensitive.

Evaluation

As always, be sure to evaluate the program that you’ve planned and make changes accordingly.

3. Does the child understand the instruction you are giving them or what is expected of them?

Level of comprehension

Be sure you know the child’s level of comprehension, in other words, does the child understand what you are asking of them. This can be gathered from a speech therapy assessment and/or report or by asking the parent or teacher what style and level of communication is most appropriate.

Information can be presented in many different ways to a child, for example:

1. 1. Verbally
      “today we are going to do some wheelbarrow races, make shapes with playdough then do some writing”.
   2. Scribing
      writing a list of the activities of the session.
      • Wheelbarrow races
      • Playdough shapes
      • Writing
   3. Video
      showing a video of how to complete the activities. You can make your own or look on YouTube.
   4. Visual format
      a visual schedule or flip book.
   5. Using the real object
      having a container of playdough or pencil to show the child or certain gloves or a vest that get worn each time the child does wheelbarrow races.

Model

Showing the child how to complete the task first, before asking them to try. This can be done by the therapist, another child or parent in the room or by video (see above)

Complete together

Complete the activity with the child first, to ensure success of the activity. For example, tie the shoelace together, hand over hand; or spread the jam and help the child cut the toast into pieces.

Understanding their role in the activity

It is crucial that the child understands their role in completing the task and what the outcome or finished product needs to look like. Clearly establish whether the activity is to be completed independently (child completes task on their own) or complementary (child and therapist each complete a sub-task alongside one another to ensure completion of whole task).

Break it down

The child might find it hard to know how to complete the whole task without it being broken down into smaller sub-tasks. This can be presented using any of the methods listed above.

Processing time

Each child comprehends and processes information at various speeds and this can be influenced by many factors including, time of the day, mood, sensory needs, and general health (e.g. sickness, lack of sleep). Some children, particularly those with intellectual disabilities can take between 1-60 seconds to process the information presented to them. Once again, a speech therapy assessment or report can help in determining the processing time required. During therapy, give the child enough time to process the information and try not to repeat yourself (verbally, gesturally etc.) during the processing time.

Forewarning

Forewarning the child can assist them in understanding what is expected of them by reducing uncertainties associated with an activity, ensure they understand when an activity is starting/stopping and give them a sense of what their role is in the activity. Forewarning can be presented at the beginning of a session/activity, as a countdown to end an activity/session, to show who and what will be involved in each session/activity and outline the role of the child (e.g. child spreads jam, adult cuts toast).

Environmental Cues

Environmental cues are cues from around a child that notify them of what is happening and what they need to do. For example, other children retrieving their hats inform the child that they need to do the same for playground time; or a bin placed next to bathroom door, for used paper towels. A therapist should think about how they can use the environment to inform a child to increase understanding and independence.

4. Does the child feel they have some sense of control of the environment or situation?

Many children say ‘no’ or refuse intervention because they feel they are losing control.

Defence Mechanism

Often this can be a defence mechanism for children, particularly if they have had a negative experience in the past. For example, someone has taken something off them and they don’t know what they will be getting it back; they have been asked to do something they don’t want to do and feel they have no escape.

In these situations, it is extremely important that the therapist has a trusting relationship with the child (see question 1 above).

Choice and control

Ensure the child has a sense of control or choice in the activities that are presented. For example, let them choose between two similar activities that work on the same goals; chose the order of activities; allow them a choice of motivating activities at the end of the session. Make sure the child knows when they can engage in their favoured item or activity, particularly if they have had to stop this in order to participate in the therapy. In these instances, ensure the child can see the items that is being taken away (in a finish box, on the table next to them, in the corner). Empower them to feel like they are in control, for example, by leading some aspects of the session.

Predictability

Creating consistent routines around sessions and activities can also give the child a sense of control as they can predict the structure of intervention and help them feel more comfortable.

And the most important, but often rarely asked question

5. Did you ask the child why they said no?

It sounds very obvious, but is often not asked! Probably the most important and first question that should be asked, provided the child has the cognitive capacity to answer it.

Enjoy, good luck and have fun!