Trauma-Informed Care in Pediatric Occupational Therapy: Supporting Safety, Connection, and Healing

Children come to occupational therapy with a wide range of experiences, strengths, and

needs. While some children may be receiving therapy for sensory processing

differences, fine motor delays, feeding challenges, emotional regulation, or executive

functioning difficulties, their behavior and participation can also be influenced by

experiences of stress, adversity, or trauma.

Trauma-informed care is an approach that recognizes the potential impact of trauma on

a child's development, behavior, relationships, and ability to participate in everyday

activities. Rather than asking, "What's wrong with this child?" trauma-informed care

encourages us to ask, "What might this child have experienced, and what does this

child need to feel safe and supported?"

This shift in perspective can make a meaningful difference in how children experience

therapy and how adults respond to their needs.

What Is Trauma-Informed Care?

Trauma-informed care does not mean assuming that every child has experienced

trauma. Instead, it means understanding that trauma and significant stress are common

and that we may not always know what a child has experienced.

Trauma can result from many different experiences, including abuse or neglect, loss of

a loved one, exposure to violence, medical experiences, accidents, natural disasters,

significant family changes, or other events that overwhelm a child's ability to cope.

Children can also experience ongoing stressors that affect their sense of safety and

security.

The effects of trauma can look different for every child. Some children may become

anxious, withdrawn, or fearful. Others may appear angry, impulsive, oppositional, or

constantly "on the go". A child may have difficulty with transitions, become easily

overwhelmed, have trouble concentrating, or struggle to regulate emotions.

It is important to remember that these behaviors are often a form of communication. A

child's nervous system may be responding to a perceived threat, even when the adults

around them do not see an obvious reason for the reaction.

Trauma-informed care helps us respond with curiosity, compassion, and support rather

than punishment or judgment.

The Core Principles of Trauma-Informed Care

While trauma-informed care can look different across settings, several key principles

guide our approach:

Safety: Children need to feel physically and emotionally safe before they can fully

participate and learn.

Trust and predictability: Consistent routines, clear expectations, and dependable

adults help children know what to expect.

Choice and control: Offering appropriate choices helps children feel a sense of control

over their environment and participation.

Collaboration: Children and families are active participants in the therapeutic process.

Their experiences and perspectives matter.

Connection: A trusting relationship with a supportive adult can help children feel secure

and ready to engage.

Empowerment: We focus on children's strengths and help them recognize their own abilities and successes.

These principles can be incorporated into pediatric therapy without requiring a child to

talk about or disclose traumatic experiences.

How Pediatric Occupational Therapists Use Trauma-Informed Care

Occupational therapists work closely with children and families during activities that can

sometimes feel challenging or vulnerable. Whether a child is working on feeding,

dressing, handwriting, emotional regulation, sensory processing, or participation in daily

routines, the therapeutic relationship is an important part of the intervention.

Here are some ways trauma-informed care may be incorporated into pediatric

occupational therapy sessions.

Creating a Safe and Predictable Environment

We strive to create therapy spaces where children know what to expect. This may

include using a consistent session structure, visual schedules, transition warnings, or

familiar routines.

For some children, simply knowing what is coming next can reduce anxiety. We may

say, "First we'll play in the gym, then we'll work on your handwriting, and then we'll

choose a game to finish."

Predictability allows children to spend less energy worrying about what will happen next

and more energy engaging in therapy.

Building Relationships Before Expecting Participation

A therapeutic relationship takes time. We do not expect every child to walk into a new

environment and immediately trust a new therapist.

For some children, the first few sessions may focus on connection, play, observation,

and getting comfortable. We may follow the child's interests, engage in preferred

activities, and allow the child to experience the therapist as a safe and predictable

person.

Connection is not separate from therapy. For many children, connection is what makes

therapy possible.

Offering Choices Whenever Possible

Children often have limited control over many aspects of their lives. They may be told

when to go to school, when to attend therapy, what activities to complete, and when to

transition.

Providing appropriate choices can help restore a sense of autonomy.

Instead of saying, "it's time to do handwriting" we might say, "Would you like to write

with the pencil or marker?" or "Would you like to sit at the table or on the floor?"

The goal is not to let a child avoid every challenging activity. Rather, we look for

appropriate ways to give children ownership and control while still supporting

therapeutic goals.

Respecting Boundaries and Body Autonomy

Children should feel that their bodies and personal boundaries are respected. We pay

attention to verbal and nonverbal signs that a child may be uncomfortable.

For example, instead of immediately providing physical assistance, we may ask, "Would you like help?" or "Can I show you?"

This is particularly important during activities involving physical touch, movement,

dressing, feeding, or personal care.

When possible, we explain what we are going to do before doing it and give the child an

opportunity to participate in the process.

Looking Beyond the Behavior

Trauma-informed care encourages therapists to look at the need behind a behavior.

If a child refuses to participate, we may consider:

● Is the task too difficult?

● Does the child feel uncertain about what is expected?

● Is the environment overwhelming?

● Does the child need a movement or sensory break?

● Is the child experiencing anxiety?

● Does the child feel a lack of control?

● Is the child tired, hungry, or otherwise dis-regulated?

This does not mean that all behaviors are acceptable or that expectations disappear.

Instead, we respond to challenging behavior while also considering what may be

contributing to it. We can maintain boundaries while remaining compassionate.

Supporting Regulation Before Demanding Performance

A child who is overwhelmed may not be ready to learn a new skill or complete a

challenging task.

Occupational therapists may use sensory and regulation strategies to help children

return to a state where they are better able to participate. This might include movement,

deep pressure when appropriate, breathing activities, rhythmic activities, quiet spaces,

heavy work, or other individualized strategies. The goal is not simply to make a child "calm down" The goal is to help the child feel safe, organized, and ready to engage.

Using Co-Regulation

Children develop self-regulation skills through relationships with supportive adults.

Before children can consistently regulate independently, they often need adults to help

them regulate.

A therapist may use a calm voice, predictable language, modeling, and supportive

"I can see this is really hard right now. I'm right here. Let's take a break together, and

when you're ready, we'll figure out what to do next". This communicates that the child's feelings are manageable and that they do not have to navigate difficult moments alone.

Focusing on Strengths and Successes

Trauma and chronic stress can affect a child's confidence and sense of competence. We intentionally look for opportunities for children to experience success.

This may mean modifying a task, breaking it into smaller steps, celebrating effort, or

highlighting a skill the child demonstrated. Instead of focusing only on what a child cannot yet do, we help children recognize what they can do and build from there.

What Can Parents Do at Home?

Parents and caregivers play an essential role in helping children feel safe and

supported. While every child and family is different, there are several trauma-informed

strategies that can be helpful at home.

Focus on Connection Before Correction

When a child is upset, connecting with them first can make it easier to address the

behavior afterward. Try acknowledging the child's experience:

"I can see you're really upset."

"That was not what you expected"

"I'm here with you"

Once the child is calm, you can talk about expectations, problem-solving, and what

could be done differently next time.

Create Predictable Routines

Consistent routines help children know what to expect. Visual schedules, timers, and

transition warnings can be especially helpful for children who become anxious when

plans change.

Try giving advance notice:

"In five minutes, it will be time to clean up."

"After we finish this activity, we're going to get ready for bed"

Predictability can help reduce the stress associated with unexpected transitions.

Offer Limited Choices

Choices can help children feel a sense of control without removing boundaries.

For example:

"Would you like to put your pajamas on before or after brushing your teeth?"

"Do you want to walk to the car or hold my hand?"

"Would you like to take a break now or after one more activity?"

Offering two realistic options is often enough.

Validate Feelings While Maintaining Boundaries

Validation does not mean giving in to every request. We can acknowledge a child's

feelings while still maintaining limits.

"I know you're really angry that screen time is over. It's okay to be angry. Screen time is

still finished."

This communicates that emotions are safe and acceptable, while boundaries remain

consistent.

Avoid Taking Behavior Personally

When children are dis-regulated, their behavior can feel personal. It is important to

remember that a child's reaction may reflect their nervous system rather than their

feelings toward the parent.

When possible, pause and ask:

"What is my child communicating through this behavior?"

The answer may be a need for connection, control, sensory input, predictability, rest, or

help managing a difficult emotion.

Help Children Identify What Helps Them Feel Safe

When a child is calm, talk about strategies that help them feel better when they are

overwhelmed.

This might include:

● Taking space

● Getting a hug or sitting near a trusted adult

● Using a cozy blanket

● Listening to calming music

● Doing heavy work or movement

● Taking slow breaths

● Drawing or coloring

● Using a sensory tool

● Spending time in a quiet space

The most effective strategy will be different for each child.

Take Care of Yourself, Too

Supporting a child through big emotions can be exhausting. Parents and caregivers also

need opportunities for rest, support, and connection. When adults are regulated, they are often better able to provide co-regulation for children. Taking a moment to breathe, stepping away briefly when it is safe to do so, or asking another trusted adult for support can help.

You do not have to respond perfectly every time. Repairing after difficult moments is

also an important part of healthy relationships.

Trauma-Informed Care Does Not Mean Lowering Expectations

One common misconception is that trauma-informed care means avoiding boundaries,

expectations, or consequences. In reality, children often benefit from having clear and

consistent limits.

The difference is in how those limits are communicated and enforced.

Trauma-informed care asks us to consider whether a child's behavior is driven by

defiance or whether the child is overwhelmed, frightened, disconnected, or lacking the

skills needed to respond differently.

We can maintain expectations while providing support.

We can say: "I won't let you hit. I know you're angry, and I'm going to help you calm your body".

We can acknowledge emotions without accepting unsafe behavior.

We can provide choices without removing boundaries.

We can hold children accountable while still communicating that they are worthy of care

and connection.

Moving Forward Together

Trauma-informed care is not a specific technique or a single intervention. It is a way of

thinking about children and their behavior.

For pediatric occupational therapists, it means creating therapy environments where

children feel safe enough to explore, make mistakes, take risks, and learn. It means

recognizing that regulation and connection are often foundations for participation. It

means partnering with families and honoring each child's individual experiences.

For parents and caregivers, it means looking for the need behind the behavior, creating

predictable routines, offering appropriate choices, validating emotions, and helping

children build the skills they need to navigate difficult experiences.

Most importantly, trauma-informed care reminds us that children do best when they feel

safe, understood, connected, and supported.

When we shift from asking, "What's wrong with you?" to asking, "What happened, what

are you communicating, and how can I help?" we create opportunities for children to

build trust, develop regulation skills, and experience success. And sometimes, the most therapeutic thing we can offer a child is the experience of having a safe adult who sees them, listens to them, and stays with them through the hard moments.