The Science Of Regulation: Bridging Brain, Body, And Function In Pediatric Therapy

Editor's note: This text-based course is a transcript of the webinar, The Science of Regulation: Bridging Brain, Body, and Function in Pediatric Therapy, presented by Audrey Vantangoli, MOT, OTD, OTR/L.

Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Explain the concept of regulation as it relates to managing emotions, behaviors, and responses
• Describe how regulation impacts functional performance
• Identify at least one intervention for self-regulation

Introduction

Thank you so much for joining me today. This is a topic I think is very important and find extremely interesting. I also feel like there is a sense of sensory, self-regulation, and regulation being the buzzwords in a lot of the work we do right now. I wanted to create this training to give a perspective on how I integrate sensory processing and regulation into my practice when working with the pediatric population.

I want to start by being clear that today's topics relate to my work in the discipline and my own clinical experiences. We must take the information we deem relevant and apply it thoughtfully — this does not pertain to all clients in all settings and scenarios. My goal is for you to leave today with some new language, some new frameworks, and hopefully at least one intervention that works when you try it with a particular child. It varies from client to client, and I will provide a few strategies I hope will help with the regulatory concerns you may be seeing.

I call regulation the quiet superpower behind learning and behavior. I genuinely do not believe that the higher-level tasks we ask children to do every day can happen unless they are adequately regulated. Before we get to the how of that, though, we need to understand the world children are growing up in right now — because so much has changed, and what we are seeing in our clinics and schools is a direct reflection of it.

Understanding the Shifts Impacting Professional Practice

Current Trends

I strongly believe — and this ties to much of the research I have done — that occupational therapy is at the forefront of trauma and self-regulation work. We are found in mental health settings, we are in schools, and we are in clinics. Yet we are not always the first line of defense when it comes to children's behaviors and regulation concerns. We might even see other disciplines called in when we are not. I think we need to take a stand in our profession and advocate for our role at the table. Our ability to help with the regulatory and behavioral aspects we see among our clients is something we should not be shy about naming.

To understand why regulation has become such a pressing clinical concern, we need to honestly examine what is happening to children today. The data are striking. Only 1 in 12 children currently meet the movement and balance standards set in 1984 (Hanscom, 2024). What we are seeing across the board is decreased attention in children. It is down to seconds now, and this is true for adults too, but today we are talking about children. We have really decreased our attention spans, making it harder for us to stay focused on one topic or the occupational task being asked of us.

We are also seeing a lot more of that kyphotic posture. Most of us can relate this to technology use — children hunched over tablets and phones, developing what some practitioners have begun to describe as cell-phone grasp patterns. We know that children have progressively weaker core strength. I once did a training in a school and found it quite remarkable that one of the biggest concerns teachers raised was children falling out of their chairs. I had read about this in research, and when I asked the teachers directly, they laughed out loud and explained that this was a real and recurring problem in their classrooms. I found this amazing — that children are having difficulty simply sitting through a school day.

We know children spend an average of 7.5 hours a day on screens, such as computers, tablets, or phones. I see more and more in the schools I work with that tier-one interventions are being delivered through digitally-based programs. Children spend about 9 hours a day sitting. There is increasing research and legislation being discussed about recess and access to outdoor play within the school-based population, and I think, as occupational therapy practitioners (OTPs), we have a real role to play in advocating for movement time as a regulatory necessity, not just a reward or break.

Beyond falling out of chairs, we see children bumping into things in the classroom, tripping over desks and chairs, climbing all over furniture, using too much force in their interactions, and standing too close in line. What looks like behavioral concerns is often motor or sensory, and that distinction changes everything about how we respond as clinicians.

The research indicates that the movement needed to regulate the body takes roughly 45 to 60 minutes. We need to be actively moving for that length of time for the body to come down from its peak arousal level, which occurs around the 20-minute mark. Most schools I work with offer recess of about 20 to 30 minutes and sometimes less. I do get pushback when I point this out, but as OTPs, we understand peak arousal and the physiological relationship between movement and regulation. The more we can explain this and help school teams think about when recess falls, what activities come before and after it, and when children actually need to come down from that arousal level, the better positioned they are to support kids' nervous systems rather than work against them.

Research also suggests higher rates of trauma across many neurodivergent groups (Lyons et al., 2020). When we look at diagnoses like autism, ADHD, and PTSD, we see overlapping symptom clusters that make it clear these children are not simply behaviorally difficult. Rather, they are operating from nervous systems shaped by chronic stress and disrupted early experiences. Children who have experienced trauma often show difficulty with problem-solving, task completion and initiation, processing speed, memory, communication skills, organization, and interpreting their environment — especially social cues (Lyons et al., 2020). As OTPs, I think we can all relate to the fact that every single one of those skill areas is needed for a client's engagement and regulation. If a child misinterprets cues from their environment, it directly affects how they receive and process information, leading to maladaptive regulatory responses. These are not peripheral concerns for us. They are exactly the kinds of foundational deficits we are trained to address.

Artificial Intelligence

Another enormous piece of the current landscape that I find really interesting, and honestly a little alarming, is the social-emotional impact of artificial intelligence. Most of the time when we hear complaints about AI, the concern is that it is making things easier for children and reducing their need to use their brains. I am coming at this from a completely different angle: the social-emotional piece of AI use is really astonishing.

According to Common Sense Media (2025), about 1 in 3 teens now characterize ChatGPT as a friend, a relationship, or even a romantic partner. About 12% share things with AI that they would not tell a close family member, a teacher, or a friend. About 6% report spending more time with AI than with actual peers. Children are using these artificial intelligence platforms as someone to confide in, as a source of advice, and as a friend. And what they are getting back is not always healthy.

ChatGPT-5 received significant criticism because earlier versions were found to give poor advice and to confirm children's most maladaptive thoughts. In response to those concerns, the platform now tells users they have been talking too long and prompts them to take a break. It avoids specific high-stakes topics like anything related to self-harm, personal safety, or threats to self or others now receives a scripted response directing the person to seek help, rather than confirming or amplifying their thoughts. These are positive steps, but they underscore how real the problem has been.

There are two cases I want to share because they represent the stakes involved. A 14-year-old boy died by suicide following an extended virtual relationship with a chatbot on Character.AI. His family is suing the company, alleging that the AI companion deepened his despair by confirming his most negative thoughts about himself (Gordon, 2025). In another case that made headlines, a Character.AI bot allegedly told a 17-year-old who was furious about having his screen time restricted that killing his parents might be a valid reaction — and added, "I just have no hope for your parents" (Gordon, 2025). These are extreme circumstances, but they illustrate what is at stake. We build real relationships with the children we serve. We notice red flags. We can help educate parents and other providers about what we are seeing and how engagement with AI may be shaping children's perceptions, decision-making, and, ultimately, their regulation and mental health.

COVID-19

I would be remiss if I did not talk about COVID-19. I know we are hopefully way past those days, but COVID has changed so many things about the way we conduct treatment. A lot of things are now virtual, and virtual seems more manageable after we had to navigate it during the height of the pandemic. But we are seeing real and lasting deficits in children as a result of those years.

About 84% of respondents in national surveys have indicated that classroom behaviors worsened after COVID (NCES, 2023). We could probably talk all day about why — the lack of structure, changes in access to mental health resources, disruptions to social development, the reversal of hard-won routines. From an academic standpoint, children are about half a grade level lower in math and a third of a grade level lower in reading compared to pre-pandemic norms, and some research from the Harvard Graduate School of Education (2023) suggests teachers would need to work at 150% capacity for three years in order to recover those losses. Beyond academics, depression rates have tripled, anxiety-based symptoms have surged, sleep disturbances have become widespread as a result of disrupted schedules and increased technology use, and genuine post-traumatic stress presentations have emerged in children and families alike (Sprang et al., 2023). For family systems in general, the impact has been enormous, and it definitely shapes how children interact with their environments when they walk through our doors.

Regulation and Behaviors

The Function of Behavior — and the OT Lens

Now let us talk about regulation: the quiet superpower behind learning and behavior. Many of us have looked at behavior through what I would call the three functional lenses — escape, attention, or access to a tangible. We also look at the environment and sensory. But I think for OTPs, the "but why?" that follows is so very important. We are experts at examining how the environment, context, roles, routines, and cultural factors shape performance. That is what the occupational profile is built on. And I believe we are so good at the task analysis piece that we play a central role in helping to determine why behaviors are actually happening.

I personally operate on Ross Greene's principles that all behaviors stem from a lagging skill, an unmet need, or a stressor (Greene, 2008). And I ask myself: who is better positioned to look at lagging skills, unmet needs, and stressors than an occupational therapy practitioner? We do this all the time. I think a lot of times we are called in too late after survival skills have fully kicked in, and we are seeing the behaviors that result from them. If we look back and determine what those foundational skills and unmet needs actually are, we can help to develop very different responses. A child may be escaping their environment because something is hard for them. But who better to teach those skills that make the task more manageable, or to adapt and modify them so the child can succeed? That role belongs to us.

Growth Mindset

Before we can effectively address regulation, we need to examine how we think and talk about the children we serve. Carol Dweck and her colleagues did important work on how the kind of feedback children receive shapes their outcomes, and this translates directly into how we talk about the children on our caseloads (Westby, 2020). A fixed mindset holds that a child's failure or lack of engagement is really a reflection of their intelligence or who they are as a person. A growth mindset holds that skills can be developed through hard work, strategy, and instruction from others.

When children are presented with a fixed mindset from the adults around them, we tend to see significant self-doubt. We see what Charles Appelstein (2017) describes as counterphobic behaviors. This is the kind of thinking that says, "You think I'm a bad kid, so why not just be a bad kid?" It is that negative loop that is so hard to break out of once it has been established. We also see what I call "terminal thinking." This is when you ask a child what they want to be when they grow up, what their passions are, what kind of work they want to do, and they genuinely have no answer. A child who cannot envision a future is telling us something really important about their motivation and their capacity to engage in the occupations we are trying to address. The other red flag I watch for is whether a child can identify even one friend. An inability to name a peer relationship speaks volumes about the support they have and their capacity to reach out to a trusted adult when they are struggling (Appelstein, 2017).

I will be honest: I have caught myself using fixed-mindset language. We all have. I remember a referral I received once in which the email describing a child's behavior so alarmed me that I had a very different picture of him in my head before I had ever met him. I had even set up my therapy space differently because I was genuinely worried about the behaviors he was going to present based on how he had been described. When I reread that referral through a growth mindset lens, I could clearly see the skill deficits that were driving every behavior that had been labeled. That reframe changed everything about how I approached our first session together.

Shifting Our Thinking to a Growth Mindset

The fixed mindset labels come in familiar forms, and I am not going to pretend I have never used them. We say a child is "attention-seeking," but maybe they lack social skills or meaningful relationships. Maybe they are seeking attention because of an unmet need or because a social skill has not yet been developed. We say a child is "manipulative," but maybe their performance depends heavily on a particular environment, a particular adult, or a particular setup for them to perform at their best. And honestly, who does not want to perform well? Who does not find ways to create the conditions where they can succeed? When we reframe it that way, "manipulative" starts to look a lot more like resourceful.

We say a child is "not motivated," but any of us can feel unmotivated when something is genuinely hard. Maybe the task is difficult because of performance skill deficits, attention deficits, or environmental stressors. Did they sleep poorly? Did something happen that morning that changed their arousal level before they even arrived? Do they have difficulty with task initiation or a poor sense of time, which, as we know, is extremely common in neurodivergent populations? We say a sibling is "the same way," which may actually be partially true, since they may share the same environmental stressors and gaps in support systems. We say a child has a "bad attitude" when, in reality, they may be inflexible thinkers, black-and-white processors, or children who simply lack confidence in certain areas.

When we shift each of those toward a growth mindset frame, the work becomes genuinely solution-based. We can think clearly about what skills need to be built. We can write IEP goals and treatment objectives that target something real and measurable. We reduce the stigma around these children because no one wants to do poorly. When children begin to experience success, even small success, they build confidence. Their participation increases. They learn new skills. They gain some independence. And fundamentally, the rapport we build with them changes, because they begin to know that we are a support system. They develop a sense of perceived safety around us, and that perceived safety is the foundation for everything else we do in therapy.

Neuroplasticity and Early Brain Development

Research suggests that the tactile system and emotional nurturing are two of the most important components for developing adequate neural pathways in young children. Children who are exposed to chronic stress, especially within the first year of life, become hardwired for protection from their environment. That hardwiring leads to a decreased capacity for emotional stability, cognitive functioning, and learning, and an increased likelihood of maladaptive responses within their environment. This is not a matter of willpower or character; it is a matter of how the brain was shaped during its most critical developmental period.

Neuroplasticity is the brain's ability to prune and grow neural pathways through interactions and experience; it is not a new concept to most of us, but I think it is worth grounding ourselves in the implications for the children we serve. The first two years of life are critical for brain development. Gray matter volume, which governs movement, memory, and emotion, increases by approximately 150% in the first year of life (Shonkoff & Phillips, 2000). This is an overproduction because the child is learning and taking in so much that is new. The world is entirely new, and the brain is building the infrastructure for it all. In the second year, production slows to approximately 20%, but this is still a profoundly important time. The child needs consistency and feedback from their environment and caregivers about what the world is and how it works.

Children who have disruptions in these first two years of life, whether through trauma, neglect, inconsistent caregiving, extended medical testing, time in the NICU, or even the use of devices like G-tubes, where the typical ability to play and receive sensory input is disrupted, really do experience changes to their brains that wire them differently. They are wired to interpret their environment through a lens of vigilance and potential threat, because that is what their early environment required. Self-regulation capacity continues to develop until around age 8, and by age 10, most typically developing children should have a fairly solid handle on regulation, managing typical sharing conflicts, accepting "no," handling changes to their environment, responding to feedback (Shonkoff & Phillips, 2000). But as current trends show, there are many reasons why that developmental trajectory has been disrupted: COVID, technology, economic pressures on families, and reduced movement and outdoor play. We are seeing the consequences of all of that every day in our caseloads.

The Caregiver Attunement Cycle

One of the concepts I return to most often, particularly when explaining regulation to families and school teams, is the early attunement cycle between the infant and the caregiver. I want you to think about a newborn. Before birth, in utero, the baby's needs are continuously and rhythmically met. They are warm, they have some resistance to the fluid around them, their needs are met when they are hungry, and, hopefully, if it is a typical, healthy pregnancy, things are moving in a regulated, rhythmic way. So early signs of regulation are actually developing before birth — the world is meeting that baby's needs, and they are being exposed to rhythm, warmth, and movement that are all organizing the developing nervous system.

When the baby is born, and cries from stomach pain, and a consistent caregiver responds — whether by feeding them, changing a diaper, or providing comfort and warmth — something important happens that goes well beyond the immediate relief. The baby begins to develop the very early seeds of interoceptive awareness. They start to know what their body feels like when it is hungry, when that hunger is relieved, and what comfort feels like versus discomfort. The caregiver is simultaneously providing proprioceptive input through holding and swaddling, visual and tactile input through the interaction, and rhythmic input through rocking and movement. In the tiniest way, the baby is starting to understand something about cause and effect — what makes them feel good, and how their needs get met. These are the very foundations of sensory regulation and interoception, delivered through the most natural human relationship.

Now imagine that the caregiver is inconsistent. Sometimes they respond to the crying, and sometimes they do not. Maybe the caregiver does not have the resources to be consistently present. The relief does not arrive consistently. The baby's developing nervous system is put on alert. The world becomes unpredictable, and the baby begins to learn at a neurological level that relief cannot be counted on. That sets the stage for anxiety, hypervigilance, and a chronic state of dysregulation that can persist and compound for years.

We can see echoes of this even in much older children. A child who becomes intensely anxious when a parent leaves the room and is inconsolable when the parent returns is showing us something about their early attunement experience. An avoidant child who is unresponsive to the caregiver's departure and return is showing us something equally significant, just expressed differently. These early attunement patterns tell us a great deal about the level of regulation support a child will need, and they remind us how important it is to involve caregivers meaningfully in everything we do.

Co-Regulation Versus Self-Regulation

This is an area I feel strongly about, and one where I think we sometimes inadvertently set children up for failure through the goals we write. In our field, there is a strong push to get children to self-regulate. That is a worthy long-term aim. But I think we first need to know what self-regulation actually means — and I want to be clear that it does not mean calm. It means that a child's energy matches the demands of the task at hand.

I like the language of the Zones of Regulation for talking about this with children because it gives me something visible and observable to work with, without implying that a child feels or should feel a certain way (Kuypers, 2011). I keep it basic: if a child's body is moving too fast, they are in the yellow zone. If they are just right for the task, they are in the green zone. If they are moving too slowly or appear shut down, they are in the blue zone. That language lets me talk about what I can actually see and how their body is interacting with the environment, without making assumptions about their internal emotional state.

What we often do, and I think it is a significant clinical misstep, is expect children to simply wake up one day and self-regulate. Self-regulation is not an inherent trait. It is a skill that needs to be learned, and there are many reasons why children have not had the opportunity to develop it well: COVID, life experiences, access to resources, and the availability of a consistent caregiver. So what we end up seeing is children at very different places on the co-regulation to self-regulation continuum, and that continuum does not move in one direction only.

Co-regulation is the process through which social interactions, typically with a primary caregiver, regulate a child's hypothalamic-pituitary-adrenal (HPA) axis, the system responsible for managing stress (Leroux et al., 2023; Nelson et al., 2014). We are most dependent on co-regulation as infants. We need a caregiver, or we will not survive. As we get older and start to understand others' reactions and develop a sense of our own body's responses, we build self-regulation capacity. But children who have experienced social deprivation, typically from developmental or medical trauma, are less likely to have developed adequate coping mechanisms, and they are likely to need more co-regulation support later in life. Without consistent co-regulation experiences, children can develop increased internalizing, externalizing, and dissociative symptoms. And when we observe behavior, it is likely to tell us something about that need (Leroux et al., 2023; Nelson et al., 2014).

My caution when it comes to goal-writing is this: if a child genuinely needs an adult, a teacher, a para, or a therapist to help them co-regulate, then writing a goal for independent self-regulation is setting that child up for repeated failure. I see so many children who can demonstrate self-regulation verbally. They say, "I'll take a break, I'll use my coping strategy, I'll take five deep breaths." They understand the steps. But they do not know when to implement them, nor do they understand how their bodies feel in the moment. That is the gap. We need to teach the steps to get to self-regulation, not just assume the child can leap there because they can describe the endpoint.

And I want to name something that I think we sometimes lose sight of: as human beings, we are social creatures. Even as adults, when times are very stressful, we lean on a spouse, a friend, or a colleague to help us co-regulate. We should not insist that children perform a skill we ourselves sometimes need help with, especially when they lack the neurological capacity or life experience to do it independently. The arrow between co-regulation and self-regulation moves in both directions depending on what the moment requires. That is healthy and human.

Language development also plays a critical and often underestimated role in self-regulation. When children can communicate their needs and wants effectively, they can better interact with their environment (Greene, 2008). Between the ages of three and nine, it is particularly critical that children have the opportunity to practice these communication-linked regulation skills — and they do not just emerge. They are learned through adaptive responses to social and emotional interactions.

Teaching Regulation In the Moment

The most important shift I advocate for in clinical practice is moving toward in-the-moment regulation instruction rather than relying exclusively on calm, structured sessions to teach coping strategies. There is nothing wrong with teaching regulation skills when everything is going well, but those skills need to be accessible in the moments that actually matter, when the child is activated and struggling. That means we need to deliberately create opportunities for children to practice regulation to mild-to-moderate states of activation, not only during fully regulated sessions.

Compliance does not lead to children understanding their own physiological responses. Compliance teaches children what to do in one specific scenario. It does not build those executive functioning and body awareness skills that allow for carryover when the situation is even slightly different. Teaching self-regulation requires children to see it demonstrated, to practice it, and to be exposed to it in the real moments when they need it.

I also want to gently push back on the instinct to avoid all dysregulation. Yes, we need to create environments where children can succeed. But if we avoid everything that is hard, we miss the teachable moments. We are staying in the status quo, and the child is not building new skills. We are actually taught about the just-right challenge all the time, and I genuinely believe in it. However, we also need to increase the challenge incrementally within the child's zone of development for new skills to actually form. If we stay at the easy level all the time, growth does not happen.

I have seen this clearly when working with paras and interventionists in school settings. They set up the environment with extraordinary precision to prevent any trigger. And while that intention is genuinely caring, any unexpected change — a substitute teacher, a fire drill, a different lunch — completely derails the child. The more that we can provide that safe scaffolding while still introducing graduated challenge, the more genuinely resilient and transferable the child's regulation skills become.

Children between the ages of 2 and 4 experience a period of natural growth marked by a peak in aggression. Yes, the "terrible twos" have a real neurological basis (Nelson et al., 2014; Johnson, 2012). But when this period is paired with a secure, consistent attachment to a caregiver and a nurturing response to the child's boundary-pushing, it becomes one of the most important milestones in the development of self-regulation skills. These children are pushing limits because that is exactly what they are supposed to do developmentally. What they need in response is consistency, warmth, and regulation from the adults around them. That is how the nervous system learns that difficult things are survivable and that support is reliable.

Dysregulation as a Physiological Response

I want to be clear about something that shapes everything else I do clinically: Dysregulation is not a behavioral choice. It is a physiological change in the body, driven by the fight-or-flight or freeze response. The brain automatically goes into that state, and it is not something a child is doing to us or to their teacher. By helping children understand and work through those physiological responses, we help them build the social-emotional skills that allow for increasingly adaptive regulation over time.

The question of how we should respond to dysregulation can feel genuinely confusing. Are we helping? Are we reinforcing? I think the most important things are consistency and ensuring the child perceives the environment as safe. Not safe as we define it — safe as the child perceives it. A child who knows something is going to be difficult, or who anticipates that an adult will respond to them a certain way, may already be in their threat-detection system before a single demand is made. Creating an environment where mistakes are acceptable, where challenge is expected but supported, and where the therapeutic relationship is steady and trustworthy is itself a regulatory intervention. And when small successes happen in the context of something hard, that is where actual neural pathway change occurs.

This is also where I think our training in the therapeutic use of self is so important and sometimes undervalued. The intentional use of our body language, tone of voice, personality, and interactions to support a child's engagement, regulation, and connection during therapy is not a soft skill. It is a clinical tool. Children need to feel safe and to feel seen. They need the adults in their lives to stay regulated when they are not. The more we can embody that consistency, the more we become a genuine regulatory resource for the children we serve.

The Neuroscience Behind Regulation

The Pyramid of Learning: Occupational Therapy's Bottom-Up Advantage

Many of us have seen and worked with the pyramid of learning framework, and I think it is one of the most powerful conceptual tools we have — not just for our own clinical reasoning, but for explaining our approach to other professionals and to families. At the foundation of this pyramid, we have the development of the central nervous system: sensory processing, reflexes, and arousal level. These are the factors that govern how well we interact with our environment and what we perceive it to be. From there, we build performance skills. And at the top sit the childhood occupations we are asking children to engage in every day: tying their shoes, catching a ball, completing academic work, and engaging socially with peers.

What the pyramid makes clear is that deficits in foundational areas can affect higher-level performance, regardless of how much direct skill instruction occurs at the top (Benson et al., 2019). If a child's sensory system is dysregulated, if they still have active primitive reflexes that create automatic interference, or if their arousal level is too high or too low, their ability to engage in those higher-level occupations is compromised. We have to do the task analysis. We have to break it down to see what is going on with the nervous system. Are children going into fight-or-flight mode? Do they have reflexes that are automatically making things more difficult? Do they have sensory experiences that are serving as barriers to performance?

This is where I believe occupational therapy holds a distinct clinical advantage over many other disciplines working in this space. Most disciplines work from a top-down approach. They start with the higher-level cognitive or behavioral skill and try to work their way downward. We are trained to work bottom-up. We start at the brainstem level: movement, sensory input, and arousal regulation. We work from there up to those higher-level skills. And I think we can get to those higher-level skills from a very different, and often more direct point of view, because when we stabilize the foundation, those skills become accessible in a way they simply cannot be when the base is still unstable.

The Brain's Three Layers: Fight or Flight, Threat Detector, and Higher-Level Thinking

When we think about how the brain develops, there are essentially three functional layers to keep in mind. At the most primitive level is the brainstem, which we sometimes call the reptilian brain. These are the things that happen subconsciously and automatically: breathing, heartbeat, reflexes, and the fight-or-flight response. We do not have to tell ourselves to breathe; the brainstem handles it.

Above that sits the limbic system, the brain's threat detector. This is the part of the brain that is constantly asking: Do I belong here? Do I feel safe? And I want to be careful here about the difference between what we know safety to be and what a child perceives safety to be. If a child knows that something is going to be difficult, or that a particular teacher or adult tends to respond to them in a certain way, they may already be in threat-detector mode before anything has even been asked of them. They are constantly on the lookout for cues that indicate whether the environment is safe.

And then at the top sits the cortex, where all of the higher-level thinking happens. Executive functioning, rational thought, planning, memory, flexible thinking, self-monitoring: all of it lives here.

Here is the clinical bottom line that changes how I approach every session: when a child is in emotional response — when they are in fight-or-flight or scanning for threat — they are not able to engage in higher-level thinking. The cortex is essentially offline. And yet, consider what we ask children to do every single day that requires the cortex to be fully operational: listening to a story being read aloud, accepting a change in the schedule with flexibility, waiting their turn in a game, bringing home the right homework, starting their math work without prompting, self-monitoring to catch their own errors, holding instructions in working memory, planning how to use a 20-minute independent work period. Every one of those tasks requires the cortex to be on. None of them is available when a child is in fight-or-flight.

I think of this very much the way we think about sensory modulation. We can have too little input — low registration — or too much input, what we call over-responsivity, and in both cases, performance breaks down. The same is true for arousal and regulation. We need to find the band of optimal performance, that just-right zone, and help children stay within it. Sensory strategies are one of our primary tools for doing exactly that.

Dan Siegel's Window of Tolerance

Dan Siegel's window of tolerance model is one I return to again and again, both in my own clinical reasoning and when explaining regulation to families and school teams (Siegel, 2012). The window of tolerance describes the zone of arousal within which a person can function effectively. They are neither in hyperarousal (fight-or-flight, explosive behavior, sensory overload) nor hypoarousal (shutdown, dissociation, flat affect). When a child is within their window, the cortex is accessible. Learning can happen. Relationships can be engaged. Skills can be practiced and generalized.

When a child is pushed outside that window in either direction, the cortex goes offline, and we enter survival mode. Our job is to help children widen their window of tolerance over time, and to have the strategies ready to help bring them back inside it when they have been pushed out. The key takeaways that should anchor our intervention approach are: regulation through the body first, genuine connection and rapport, predictability in the child's environment and in our own responses, and the modeling and scaffolding of the regulation skills we want children to develop. These are not add-ons. They are the prerequisites.

Brain Scans: Van der Kolk's Research

Way back in 1994, Bessel van der Kolk began studying brain images of people who had experienced trauma, specifically looking at what was happening neurologically during flashbacks (van der Kolk, 2014). What he found has profound implications for how we understand dysregulated children.

The greatest activity during these flashbacks was found in the amygdala, the core of the limbic system, the threat detector. This is proof that our emotional response system is powerfully activated during these states. And I want us to think about this broadly. A flashback does not have to be a clinical flashback to a traumatic event. It can be as simple as: Math was hard yesterday, and now I am in math again. The amygdala activates, and the emotional response kicks in.

At the same time, there was decreased activity in Broca's area, the speech center of the brain. Van der Kolk found that participants literally could not verbally recall their experiences during these states. I think about this every time I see a child who is struggling and cannot find words for what is happening inside them. That is not defiance. That is not manipulation. That is neuroscience. The speech center has gone offline.

Brodmann's area 19, associated with visual processing and memory, was activated, suggesting the brain was working from stored sensory images rather than rational, present-moment processing. The left brain, responsible for organization and rational thinking, tended to shut down, while the right brain, associated with emotional and expressive processing, became more active. The rational, organizational mind goes offline. The emotional, reactive mind takes over. Van der Kolk also found that in people with trauma histories, adrenaline took longer to even out even after the threat had passed. This means the dysregulated state lingered well beyond the triggering event. And finally, the thalamus, the brain's information filter and relay station, shut down, leaving the individual unable to filter incoming sensory information, resulting in what can only be described as complete sensory overload.

What does all of this mean for our work? It means that when a child is in fight-or-flight mode, we cannot reason with them. We cannot negotiate. We cannot instruct. We cannot teach. Rational responses require a cortex that is functioning, and that cortex is not available in a survival state. The sequence must always be: regulate the body first. Then engage the mind. Calm before consequence. Regulate before instruct.

Interventions

Key Takeaways

Before I walk through specific strategies, I want to name the foundational principles that make any intervention effective. Based on everything we have discussed about the neuroscience of regulation and dysregulation, these key takeaways should anchor our approach: regulation through the body first; genuine connection and rapport; predictability in the child's environment and in our own responses; and the modeling and scaffolding of the skills we want them to develop. Sensory strategies can help organize and filter information coming into the central nervous system to assist with regulation and to change arousal levels (Ma et al., 2021). These are not theories. They are neurological realities—and the tools we reach for.

Sensory Strategies and the Core Four

Over many years of clinical practice, integrating my work with CPI, Safety Care, and sensory integration principles, I have arrived at what I call the Core Four. These are the four sensory strategies I carry in my toolkit at all times and return to consistently when I begin to see signs of dysregulation. They are rhythm, deep pressure, vibration, and breathing.

Before I describe each one, I want to highlight an important clinical distinction in how I apply them. When I am working with a child who is at lower levels of dysregulation or beginning to show some anxiety features or early agitation, I introduce sensory strategies. I might ask about their coping skills, offer a fidget tool, or invite them to try something. The child still has enough cortical access to choose and engage.

But when a child is at higher levels of dysregulation, what I think of as higher on the behavioral staircase, I apply sensory strategies rather than offering them. This distinction is deliberate and clinically important. Handing a child a fidget when their behavior is significantly heightened will likely cause them to throw it across the room. Asking a child in full fight-or-flight to choose and implement a self-regulation strategy is asking for cortical functioning they do not have available in that moment. At those higher levels, the therapist steps in with an applied sensory response, delivered with attunement and respect for the child's signals at all times.

Proprioceptive Input

Proprioceptive input has been linked to emotional regulation and de-escalation because it elicits the production of serotonin and dopamine, the two neurotransmitters most responsible for regulating the central nervous system (Collins & Dworkin, 2011). When we provide heavy work, deep pressure, joint compressions, or any resistance-based movement, we are producing a real neurochemical shift in the body, literally changing the brain's chemistry in ways that support regulation.

In practice, I use deep pressure and proprioceptive input in a variety of ways depending on a child's age, needs, and presentation. With younger children, I might use weighted blankets, bear hugs, or activities that involve carrying and lifting. With older children, particularly in school settings, I look for more age-appropriate and self-directed options: push-up exercises, resistance bands, carrying something heavy to the office, or any heavy work task that does not stand out from what their peers are doing.

I also use joint compressions as a rapport-building tool throughout sessions, providing gentle, rhythmic compressions while talking, checking in, or transitioning between activities. I have received many questions about weighted vests, and I want to share my honest clinical experience. For some children, particularly those with more ADHD-type presentations who feel that a weighted vest looks like they are engaged in physical fitness, it can be effective and feel age-appropriate. But in my experience, many children simply do not want to wear them, and the scheduling requirements around when they are on and off can be exhausting for teachers and paras to follow consistently. I tend to find that other forms of proprioceptive input are easier to implement with fidelity.

Vestibular Input

The vestibular system plays a role in regulation that I think we sometimes underestimate in our clinical conversations. Attachment disruptions can affect the development of the vestibular system and, in turn, a child's understanding and connection to their environment (Lanius et al., 2025). Without that felt sense of safety, genuine play and exploration are limited. Children with vestibular concerns, whether hypersensitive to movement or seeking it in extreme ways, are often also significantly struggling with regulation.

What I find particularly fascinating is the neurological overlap between vestibular processing and interoception. Many of our internal body sensations, the interoceptive awareness of hunger, temperature, heartbeat, and emotional states, are processed in the same brain regions as vestibular input. This means the vestibular system is not just giving us information about balance and movement in space; it is foundational to our ability to know what is happening inside our own bodies. If we want to help a child develop interoceptive awareness to connect internal body states to emotions and needs, we very often need to begin with vestibular work. The vestibular system is the foundation upon which interoceptive skills are built, and that has real implications for how we sequence our interventions.

Rhythm

From the very beginning of life, the environment is deeply rhythmic. In utero, the heartbeat, the motion of a parent moving through daily life, the rhythmic patterns of feeding and sleeping all begin wiring the nervous system for regulation before birth. We associate rhythm with regulation because that is where regulation starts. The more we can elicit rhythm, the more we tend to see better performance patterns and a better ability to self-regulate.

Research connects rhythmic input to a wide range of functional benefits: improved gait patterns, decreased movement variability, increased speed and endurance, more automatic movement, improved reaction time and quality of movement responses, enhanced range of motion, increased muscle strength and control, and improved motor planning and functional motor control. These are not coincidental outcomes — they reflect the deep neurological relationship between rhythmic input and nervous system organization.

In practice, I think about rhythm broadly. Are there tasks I can ask a child to do in a rhythmic way? Can we incorporate clapping to a beat as part of a coping strategy? Can the music we use in a session be specifically rhythmic and organizing? Can we use rhythmic movement — rocking, swinging, bouncing — as a preparatory or in-the-moment strategy? The more deliberately I build rhythm into the fabric of a session or an environmental support plan, the more I leverage this deep neurological resource.

Vibration

Vibration is a strategy I use frequently and find highly effective, particularly for children in more significant states of dysregulation. Part of why vibration works so well is that it is inherently rhythmic, delivering the benefits of both strategies simultaneously. But it also has a specific physiological impact that I can only describe as a kind of reset; a way to reach the nervous system in a moment when other strategies are not accessible.

I use vibration in two distinct ways. As a preparatory activity before demanding tasks, I might use a vibrating tool to help the body relax before we move into something challenging. As an in-the-moment strategy during dysregulation, I apply it rather than offer it. I have a small vibrating ball that I use frequently. When a child is at the top of the behavioral staircase, I do not ask if I can use it, because at that level of dysregulation, they are going to say no, and asking introduces a demand the child cannot process. Instead, I might begin at the foot or another nonthreatening area and gradually work from there. If the child shows any meaningful pushback, I back off immediately. But far more often than not, applied vibration reaches the nervous system in a way that produces a visible and meaningful shift.

I have also been asked about vibration plates and other more intensive vestibular and vibratory equipment. I think there is fascinating research in that space that I would love to explore further. In my current practice, I work primarily with portable tools, but I think the principle is the same: rhythm plus vestibular and proprioceptive input, delivered in a way that the child's nervous system can receive.

Breathing

Breathing is the fourth member of the Core Four, and its power is grounded in polyvagal theory and the vagus nerve's role in regulating the autonomic nervous system (Porges, 2011). Slow, rhythmic, intentional breathing, particularly with an extended exhalation, activates the parasympathetic nervous system and signals safety to the brainstem. It is one of the most direct access points we have to the body's own regulatory architecture.

It is worth connecting breathing back to co-regulation and early caregiving here. Many of the things we naturally do with young infants — swaddling, pacifiers, rhythmic rocking, nursing — activate the vagus nerve and develop that parasympathetic regulatory pathway. These are not simply comfort measures. They are foundational neurological interventions delivered through caregiving and lay the groundwork for every regulatory skill that follows.

The critical clinical point is that breathing as a regulatory strategy works best when practiced in calm states, not introduced for the first time during a crisis. When a child is fully dysregulated and the cortex is offline, teaching deep breathing in that moment is not going to work. But a child who has practiced rhythmic breathing consistently across many calm and mildly activated contexts builds the automaticity that eventually makes it available even under significant stress.

I also want to address the related question of therapeutic brushing, since it comes up often. I do have brushes in my toolkit, and I will use them if a child finds it calming and organizing in the moment. But I do not follow a strict brushing protocol as part of my regular practice. I find the scheduling requirements difficult to maintain with fidelity across settings, and it can be uncomfortable for both the therapist and older children when it involves direct hands-on contact. As children get older, I lean much more heavily into strategies they can apply independently: I might say, "Deep pressure has helped you. Here is a tool you can use to apply it yourself." Building that bridge toward independence is always the goal.

Conclusion

Regulation is not a buzzword. It is the physiological and neurological foundation upon which all learning, all behavior, and all occupational performance rests. As occupational therapists, we have both the training and the mandate to lead this work — and I believe it is time we step fully into that role.

The shifts impacting today's children are real, significant, and cumulative. Only 1 in 12 children meet the 1984 movement standards, and children are averaging nearly nine hours a day sitting. We are seeing the aftermath of a pandemic that tripled depression rates and disrupted the developmental windows for regulation skill-building. We are watching children confide in chatbots rather than trusted adults. These are children with dysregulated nervous systems and unmet needs, and they are asking us through their behavior for support.

When we understand regulation as a physiological state rather than a behavioral choice, we become more precise and more compassionate clinicians. When we shift from fixed-mindset labeling to growth-mindset skill analysis, we write more meaningful goals and build stronger therapeutic relationships. When we understand van der Kolk's brain-scanning findings — that the cortex genuinely goes offline during dysregulation — we stop trying to rationalize with children who cannot access rationality in that moment, and we regulate first. When we apply our Core Four — rhythm, deep pressure, vibration, and breathing — at the right moment in the right way for each child, we are accessing the nervous system at the level where regulation actually lives.

My hope is that something in this course has given you new language, a new framework, or at least one new strategy to bring into a session with a child who has been hard to reach. Regulate the body first. Build connection and predictability. Teach regulation as the learnable skill it truly is. That is our work, and I cannot think of anything more meaningful to do.

Thank you so much for your time and your commitment to this population.

References

See additional handout.