Push-in therapy is one of the things that happens more often once a child has already reached Tier 2 support and is officially on our caseload. Instead of pulling them out, we start looking at how support can happen within the classroom itself.
I want to start with a story because when I say “push-in,” I know reactions are mixed. For some therapists, it feels comfortable and collaborative. For many others, it can feel like a complete waste of time and a misuse of therapy skills.
Which is exactly how I initially felt.
I was working in a preschool, and at the beginning of the year the teacher and I were trying to figure out schedules. She wanted me to choose which hours I would be taking children for therapy – except technically it was still “push-in” because we remained in the same classroom. To me, it felt like behavior management. I felt more like an aide trying to keep a child on track during a lesson than a therapist using clinical skills.
There were multiple therapists working in the same setting on overlapping days, and the teacher didn’t feel comfortable having children miss classroom lessons to leave for therapy. But at the same time, there were very few suitable spaces to actually provide therapy. Often, we would work behind the circle time area, dealing with loud music, distractions, and interruptions.
It also started to feel like a power struggle. The teacher had her curriculum, responsibilities, and goals. We therapists needed her to release some of that control so we could do our work. Eventually, one of the things she asked was whether I could help run or co-teach groups in the classroom. I was not especially excited about doing more groups, but I opened myself up to the idea and started experimenting with different methods.
That completely transformed how I understood integrated services. It transformed how we viewed children, how occupational therapy goals were structured, and how speech-language pathologists, physical therapists, and other clinicians approached support within the classroom.
Why So Many Therapists Struggle With Push-In Therapy
We sent out a questionnaire asking therapists about their experiences in schools – what was going well, what felt difficult, and what they were struggling with most.
The responses were incredibly consistent:
- Clinicians are feeling completely overwhelmed with caseloads and waiting lists
- Push-in can make therapists feel like “just another set of hands in the room”
- One-on-one therapy often feels disconnected from what happens in the classroom
- There is frustration when therapy progress does not carry over into real classroom participation
This disconnect matters.
Sometimes in school-based practice, we still approach therapy from a medical model perspective. But education and therapy are constantly evolving, and we have to evolve with them. One of the biggest shifts happening in schools is the move toward more inclusive practices.
The more we can grow alongside educational services, the more relevant our role becomes within those spaces.
What Is Push-In Therapy?
Push-in therapy involves therapists delivering services within the general education or self-contained classroom so students receive support in their natural learning environment.
The emphasis is on collaboration between teachers and support staff, with interventions integrated into everyday classroom activities rather than separated from them.
Why Push-In Therapy Matters
- Inclusion and Reduced Stigma
Students are not being singled out or removed from their peers. They remain in the classroom, participating alongside classmates and learning in context. - Better Generalization
When skills are practiced in real time within the classroom, carryover becomes much stronger. Therapy becomes immediately relevant to the child’s actual day. - Legal and Ethical Alignment
Push-in therapy aligns with least restrictive environment goals and inclusive educational practices.
Different Ways Push-In Therapy Can Look
Push-in therapy does not have to mean simply sitting beside a child during instruction. There are many ways therapists can structure integrated support.
Co-Teaching Models :Therapists and teachers jointly plan and deliver instruction, integrating therapeutic strategies directly into classroom activities.
Consultative Services: Therapists provide guidance to teachers on embedding therapeutic techniques into routines and classroom participation.
Integrated Therapy Sessions: Therapy happens within the classroom itself, allowing real-time application of skills during natural activities.
For many therapists, especially those moving toward workload rather than caseload models, this already fits naturally within Tier 1 and Tier 2 supports.
Types of Push-In Therapy Models
- Team Teaching: Both professionals share instruction responsibilities and co-deliver lessons to the entire class.
- Parallel Teaching: The class is divided into two smaller groups, with each adult teaching the same lesson.
- Station Teaching: Students rotate through stations led by different educators or therapists.
- Alternative Teaching: One instructor leads the larger group while the other provides targeted support to a smaller subset of students.
- 1 Teach, 1 Assist: One professional teaches while the other circulates and provides support.
- 1 Teach, 1 Observe: The therapist observes participation and engagement in real time to identify needs and adjust support.
How to Decide What Type of Push-In Is Best
When deciding on the best push-in approach for a child, there are several important factors to consider. The first is the child’s actual goals and needs. We need to think about whether the child would benefit from peer support, whether the goals can transfer naturally into the classroom environment, and whether those goals can be framed around participation rather than isolated skill work. In many cases, classroom participation itself becomes one of the most meaningful therapeutic outcomes.
It is also important to consider the teacher’s perspective. Some teachers may worry about interruptions to the curriculum, while others may feel uncertain about having additional adults working within the classroom space. Understanding these concerns and establishing open collaboration can make a significant difference in how successful push-in support becomes.
The classroom dynamics also matter. We need to think about whether the classroom is self-contained or general education, how many adults are already supporting instruction, and whether there are multiple children with shared needs who may benefit from a group approach. We also have to consider the child’s social comfort and whether push-in could unintentionally impact their social capital or confidence within the peer environment.
Timing is another critical factor. The most effective push-in therapy happens when support fits naturally into the flow of the school day and aligns with classroom activities where the targeted skills are genuinely needed.
Finally, flexibility is essential. Push-in strategies should be adaptable over time, allowing therapists to embed support, provide coaching, and adjust the level of intervention as needed. The ability to grade activities and shift approaches when necessary is often what makes push-in therapy truly effective.
Why Group Work Can Transform Push-In Therapy
A huge part of successful push-in therapy comes down to strong group work.
In traditional push-in, there is not always enough opportunity for true grading or individualized support. Sometimes goals are not fully achieved because the therapist is simply supporting participation in the moment.
Groups change that.
Groups allow therapeutic processes to be intentionally embedded into the activity itself. Goals can be graded during both planning and implementation. Children are actively engaged, and both individual goals and group-wide benefits can happen simultaneously.
What Is Group Work?
Group work is any therapeutic service provided to two or more children at the same time with shared or complementary goals.
This could include:
- Small pull-in groups
- Push-in groups embedded across the classroom
- Structured groups with defined roles
- Open-ended or play-based groups
The key difference is intentionality. We are intentionally using the presence of peers as part of the therapeutic process.
Group work may appear “less individualized,” but in reality it is often highly structured, graded, and goal-directed.
Why the Peer Environment Matters
One of the biggest benefits of push-in therapy and group work is the social context.
Some goals need the “pressure cooker” of a peer environment to truly emerge.
For example, I might receive a referral for executive functioning difficulties. During individual therapy, everything may appear fine. The child attends, completes tasks, and participates appropriately.
Then we observe them in the classroom and it becomes an entirely different situation. The peer environment changes the demands completely.
That context matters.
Push-In Group Ideas in Preschool Settings
Some examples of groups that can work well within preschool settings include:
- Scissor skills groups
- Gross motor groups
- Fine motor and visual perceptual groups
- Food preparation and tactile groups
- Endurance groups
- Play groups
- Inclusion and social play groups
There are also many other possibilities:
- Computer-based social groups
- Activities of daily living groups
- Peer playgroups
- Trampoline groups
- LEGO groups
- Cooking groups
Often, these groups are built directly from what we observe during evaluations and from goals already identified in therapy planning.
For example, a “play group” may actually contain numerous embedded speech-language goals. The activity itself becomes the social context through which goals are addressed naturally.
Planning Push-In Therapy Groups
When planning groups, we cannot simply label something “sensory motor group” and move on. We need to think critically about whether the group works within a push-in model.
Questions to ask include:
- What common ground exists between the children?
- Can scheduling realistically work?
- What should the group size be?
- How many staff members are needed?
- Would co-treatment be beneficial?
- What performance components are being targeted?
- Is the goal shared across the group?
- Can goals be graded within the activity?
- What type of group structure makes the most sense?
Tips for Running Successful Push-In Groups
- Prioritize Peer Interaction
Children should be interacting with each other rather than simply completing worksheets independently. - Use Icebreakers
Children need time to warm up to the environment, expectations, and group structure.
We have a great resource guide with some ice-breaker ideas you can find here - Include Follow-Through Activities
Homework projects or paired activities can extend engagement beyond the group itself. - Build Trust
Trust is one of the most overlooked parts of group work.
The group structure itself should invite participation so therapists are not relying on constant discipline or redirection. There should always be opportunities for child-led interaction and play.
Tips for Running Successful Push-In Groups
Prioritize Peer Interaction
Children should be interacting with each other rather than simply completing worksheets independently.Use Icebreakers
Children need time to warm up to the environment, expectations, and group structure.
We have a great resource guide with some ice-breaker ideas you can find hereInclude Follow-Through Activities
Homework projects or paired activities can extend engagement beyond the group itself.Build Trust
Trust is one of the most overlooked parts of group work.
The group structure itself should invite participation so therapists are not relying on constant discipline or redirection. There should always be opportunities for child-led interaction and play.
Evaluating and Adjusting Push-In Therapy
Once a group has moved beyond the initial setup stage, evaluation becomes essential.
Very often, by around the six-week mark, adjustments need to happen. Goals may need to change because the child presents very differently in a peer environment compared to pull-out therapy. Staffing may need to shift. A group may become the ideal setting for co-treatment with another therapist. Environmental changes may also be necessary.
Ultimately, just remember that push-in therapy should remain flexible and responsive.
Final Thoughts on Push-In Therapy
Push-in therapy can be an incredibly effective tool for providing services within the least restrictive environment. But it also has the potential to feel ineffective when it is poorly structured or too narrowly defined. If we want our work to feel meaningful and impactful, we need to widen our understanding of what push-in can look like. That means exploring co-teaching, group work, embedded support, consultative models, and collaborative planning.
Most importantly, we cannot overlook trust and relationships. The relationships between therapists, teachers, and children – and between the children themselves – are often the real catalyst for meaningful participation and growth.
This is just a glimpse: get the full interview plus 11 other expert-led talks on mastering MTSS in schools.
About Holly Peretz
Holly Peretz is a Pediatric Occupational Therapist with 14+ years of experience working with children and parents as a therapist and parent educator within hospitals, NGO’s preschools, hydrotherapy, and online. Through her work at Precision CPD she aims to better the services provided to children through quality professional development events, content, and courses for professionals working with children.