Children who resist therapy for mental health conditions, such as depression and anxiety, present many challenges, but even the most difficult case is surmountable according to Psychologist Jay Anderson.

Mrs Anderson, a specialist in child-centred play, has encountered therapy-resistant children, but with the right approach the majority can be treated, she said.

“I’ve seen hundreds of children in over ten years of therapeutic involvement.  I can only think of a couple of children that were non-responsive.”

One child with severe anxiety didn’t understand they could control their emotions, said Mrs Anderson, and it turned out the family was facilitating avoidance behaviour. 

This included homeschooling due to school refusal and leaving the child at home instead of participating in family outings, said Mrs Anderson.

“The child was fine in their opinion as there were no tantrums when the child was allowed to avoid circumstances or situations that increased the anxiety. 

“Like with adults, some child clients may present with a particular mindset, negative thought patterns or particular personality features that mean they are in some way either resistant to treatment, or not improving, so, therefore “treatment-resistant,” said Mrs Anderson.

This negative mindset was the case with a depressed child who refused to discuss their thoughts and feelings because they didn’t believe things could change, explained Mrs Anderson.

“There was a strong mindset that nothing was going to help and things would not improve.”

In this case, treatment couldn’t be facilitated, and the child was referred to the Child and Adolescent Mental Health Service for intensive therapy and further psychiatric assessment.

This is rare, said Mrs Anderson, as most children will connect with a play-based or creative therapy as part of an interpersonal process and will establish a therapeutic relationship with their therapist.

“Even children who are aggressive or don't want to attend will connect with a therapist who is listening and non-judgemental.”

Expressive therapies, such as art, music, movement and sand-play, are important techniques that allow children to express emotions differently to the ‘talk-based’ model, which may be confronting, said Mrs Anderson.

“As a result, they are enabled to work on the issues presented in either a subconscious, indirect, conscious or direct way.

“I have found the 'multiple intelligences model' helps in understanding that not only do we learn differently, but different therapeutic techniques will engage different people.

“So, it's important for therapists to have a few different tools in their toolbox.

“Clinicians don't have a magic wand or special powers, ultimately the child needs to be self-aware, learn strategies and make changes,” said Mrs Anderson.

Deb Hopper, an occupational therapist at Life Skills 4 Kids, treats children with anxiety when their behaviour interferes with daily activities.

“Children who are therapy-resistant are often stuck in a stress response. Their amygdala and limbic system are on high alert and overload, and their frontal cortex is unable to reason and think through strategies.

“Children with anxiety often feel like their world is out of control and they struggle to rein in all the felt expectations of what they need to and are expected to do.”

The first step to engaging with these children is to help calm their nervous system and body through bottom-up or body approaches, said Ms Hopper, which can include deep touch pressure through massage, rolling a therapy ball over them, a heavy object on their lap or play based strategies.

“When we calm the body, the limbic system is calmed, and the frontal cortex can come back online, and we can support them to get a strategy together.

“When the child is calm, the second step involves helping them to break down the task through task analysis into smaller sub-steps, a top-down or cognitive approach.

“Children love to do this through social or sensory stories. Social-sensory stories are important as they reinforce both the bottom up calming strategies for the body as well as the cognitive strategies.”

Throughout this process, it’s vital to develop a trusting relationship between the therapist and the child and to use a combination of sensory or cognitive and relationship strategies to support their self-regulation and willingness to participate in play-based activities, explained Ms Hopper.

“In my experience, play-based activities work best for therapy-resistant children. In particular, I love the Theraplay® approach which looks at how a child interacts with their carer in the four domains of engagement, structure, nurture and challenge.”

Theraplay is a short-term attachment-based intervention utilising non-symbolic, interactional play to re-create experiences of secure attachment formation and can be integrated into treating children with behavioural and mental health concerns.

“This approach is ideal in understanding the underlying reason ‘why’ the child is struggling, resistant or oppositional to therapy and provides guidance in the direction for how to move forward in treatment,” said Ms Hopper.