The Therapy Role In Trauma-Responsive Pediatric Practice

Editor's note: This text-based course is a transcript of the webinar, The Therapy Role in Trauma-Responsive Pediatric Practice, presented by Dr. Audrie Vantangoli, MOT, OTD, OTR.

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

Learning Outcomes

After this course, participants will be able to:

• Describe trauma's influence on the development of emotional, cognitive, social, and physical skills.
• Explain how trauma can impact participation in meaningful childhood activities and relationships.
• Identify key strategies for implementing trauma-based interventions.

Introduction

Thank you for joining me today on a subject I am so passionate about. I have worked with many people across the lifespan who have experienced trauma in their lives, and I have seen firsthand the profound impact it has on daily performance and participation. That fascination led me to research this topic more deeply, and it has become something I return to regularly in my clinical thinking. I believe occupational therapy has a uniquely important role in this space.

Before we get started, I want to acknowledge a few important limitations. I will be speaking in general terms about many interventions and trauma-based strategies, and I want to be clear that not every approach works for every patient. My examples will lean toward a pediatric perspective, but the skills and interventions we discuss carry across settings and populations. Please hold that in mind as we go.

I will also weave in concepts from the OTPF-4, specifically performance skills, client factors, and context. Trauma, in my framework, lives squarely in that context and client factor space. Clients bring to the occupational therapy process their knowledge about their life experiences and their hopes and dreams for the future (AOTA, 2020, p. 20). We never fully know what experiences our clients arrive with, but we do know that everything they have lived will shape how they respond to treatment, how willing they are to participate, and how quickly they are able to build rapport with us. That last piece is especially important in trauma-informed care. Rapport is not a nice-to-have. It is often the prerequisite to everything else.

Meaningful Childhood Occupations

One of the things I hear frequently from practitioners across settings is how much has changed in the occupational landscape for children. I think we could spend an entire course just on that topic. But to set the stage for our conversation about trauma, I want to start by naming what is at stake for the children we serve.

When I think about meaningful childhood occupations, I think about three broad areas: school, social interactions and play, and activities of daily living. Within school, the performance skills that matter most are executive functioning, interpersonal relationships, self-efficacy, and the ability to self-monitor and advocate. I work with many children for whom these skills are significantly underdeveloped, and some of that underdevelopment is directly tied to trauma. As children get older, these are the exact skills they need to be independent and successful, and it becomes increasingly difficult to close the gap.

Social interaction and play have changed enormously in recent years. The rise of social media, the prevalence of electronics, the impact of COVID-19 on peer interaction, and the shrinking access to playgrounds and unstructured movement have all shifted how children develop and perform. We are seeing real consequences of these changes in our caseloads.

Then, there are activities of daily living, which consistently arise across virtually every setting in which occupational therapy practitioners (OTPs) work. Can a child participate in and be independent in their daily routines? These occupations are deeply interconnected. Sleep deprivation, for example, causes poor postural control and increases the risk of accidents in children just as it does in adults (Owens, 2014). Not all children receive adequate sleep or nutrition. Many cannot name a single non-electronic activity that brings them joy. I spend a meaningful portion of therapy with some of my kids on occupational exploration, looking for things that spark interest and engagement. When that baseline curiosity is absent, I see the downstream effects in the rising rates of anxiety and depression we are all encountering. Occupational therapy needs to be at the forefront of addressing that mental health picture.

Typical Development: Setting the Foundation

Before we can meaningfully explore how trauma impacts development, we need a shared understanding of what typical development looks like. I know that milestones are something we all have opinions about, shaped by the populations we serve and the variability we see every day. But I want to walk through a few foundational areas, because trauma's impact only makes sense against that backdrop.

Neuroplasticity

The brain is, as I like to say, a truly magical thing. It can learn, grow, and prune what it no longer needs. What I believe is most clinically important for our purposes is understanding how rapidly the brain develops in those first two years of life.

In the first year, the brain is overproducing gray matter at approximately 150% the typical rate. It is essentially absorbing everything. By the second year, that pace slows considerably, but learning continues at around a 20% annual rate and continues to increase until approximately age eight. Research suggests the window extends to about eight to ten years old. Think about what that means. Children are absorbing language, movement, sensory experiences, relational patterns, and skill sets at an extraordinary rate during this window. We often say to learn a skill or a second language early because it is simply easier when the brain is in this phase of growth.

The problem with trauma is that when it occurs early in life, it is hitting these skills and this developmental trajectory at exactly the most vulnerable moment. Trauma related to relationships and caregiver responsiveness, in particular, tends to occur during this critical period. I recently read a study suggesting that if early intervention does not begin promptly, the developmental gap can be so significant that even kindergarten may be too late a starting point, because the skill deficit is already too large to close easily. I think research varies on exactly where that line is, but the core message is clear: early awareness and early responsiveness to possible traumatic events or disruptions in caregiving are not optional. They are essential.

As children move into puberty and adolescence, the brain begins pruning unused connections. The gray matter thins at roughly 1.5% per year, and white matter grows in areas related to social sensitivity and information processing. One thing I want to flag here is the relationship between malnutrition and brain development, which I think often gets overlooked. If we are working with a child experiencing any degree of malnutrition, we need to consider how that affects myelination. Nutrition changes can drive significant developmental changes, and we should be thoughtful about including that in our clinical picture.

Finally, the prefrontal cortex, the region most associated with planning, judgment, and impulse regulation, does not fully develop until the mid-20s. Some current research suggests this is less a straightforward cause-and-effect relationship than we once thought, and that adolescent behavior may be more tied to reward-seeking and peer belonging through the ventral striatum than to simple prefrontal immaturity. I find that framing compelling and clinically useful, and I am curious to see where future research takes it.

Primitive Reflexes

Primitive reflexes are a hot-button topic right now, and I want to speak to them directly because I believe they are underutilized as a clinical lens, particularly for children whose presentations are a little puzzling.

Primitive reflexes should, in an ideal developmental trajectory, be integrated by year three. They are essential during the birthing process and for early navigation of the environment. An immature motor cortex allows these reflexes to promote growth in the temporal-parietal-occipital cortices, which then feed forward into prefrontal development. As the frontal cortex matures, it inhibits those primitive reflexes. This is a bottom-up process: reflexes promote the growth of higher-level brain structures, which then suppress the reflexes as they become unnecessary.

I have tested many children for primitive reflex integration, and I believe it answers clinical questions that are otherwise hard to answer. When I see a child whose motor coordination is slightly off, whose attention seems dysregulated in ways that do not fully fit the ADHD picture, or whose performance is inconsistent in ways that do not track with anything else, retained primitive reflexes often explain what I am seeing. About 30 to 50% of children with ADHD have motor difficulties, and many of those are related to the vestibular system (Story, 2026). We also know that children who have not had safe, consistent vestibular experiences early in life, meaning the rocking, cuddling, and movement that happens when a regulated caregiver is present, may not have the foundational vestibular development that supports later motor coordination and attention. The brain and body connection, the felt sense of safety in one's body, stems significantly from those early movement experiences.

For clinicians who want to go deeper on this topic, I highly recommend the work of Karyn Purvis. I have found her framework on neurodevelopment and primitive reflex integration to be thorough, accessible, and clinically grounding.

Developmental Milestones and the Case for Crawling

When we talk about developmental milestones, most of us are familiar with the CDC framework, which indicates that approximately 75% of children successfully perform a given task at a given age. I want to flag something here that has concerned many of us in the therapy world: in March 2022, the CDC removed crawling as a milestone.

This matters for a few reasons. First, physician referrals often depend on whether something deviates from a milestone. If crawling is no longer a milestone, some physicians may be less likely to refer. Second, insurance reimbursement is tied to documented developmental delays. Without a milestone to anchor the concern, it can become harder to justify services. And third, we know that the best outcomes come from early detection and treatment. If we cannot compare what we are seeing to a recognized milestone, it becomes harder to articulate the evidence base for our intervention.

I think we need to continue advocating for consistency in early detection and for the profession to name clearly what OTPs observe and know about the developmental importance of crawling. A study by Frazsen and Vesser (2010) found that 82.4% of non-crawlers demonstrated inefficient grasp patterns, a statistically significant difference (p = 0.003), and that crawlers outperformed non-crawlers on the DTVP-2. Crawling builds body schema, motor planning, visual-perceptual skills, and hand-eye coordination, and lays the groundwork for tactile, proprioceptive, and motor movement patterning. It is not simply a precursor to walking. It is foundational for a wide range of later skills, and dismissing it as optional misses that clinical significance.

Understanding Trauma

Defining Trauma

Let's now turn to the central subject of this course. I want to start with a definition because I think there are a lot of misconceptions about what trauma is and what it looks like.

Individual trauma results from an event, series of events, or set of circumstances that an individual experiences as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's physical, social, emotional, or spiritual well-being (Ranjbar et al., 2020, p. 1).

The keyword in that definition is experienced. Trauma is not defined by the event itself. It is defined by the individual's internal experience of that event. Something can be traumatic for one person and not for another. Trauma can be a single event or a series of smaller events that accumulate over time. It can be something that looks minor from the outside and feels catastrophic from the inside. And critically, it is an individualized process. I want us all to be careful about comparing the trauma load of one child to another. We should never imply that a child should be performing better because someone else has experienced more.

One of the most robust findings in the trauma literature is that the amount of support a person receives after a traumatic event is one of the most powerful predictors of how well they recover from it. We, as therapists, may be the only person on a child's team holding that holistic view and building that consistent, supportive relationship. That is not a small thing. That may be the most important thing.

Adverse Childhood Experiences

Most practitioners working in trauma-informed care are familiar with the Adverse Childhood Experiences (ACEs) framework. ACEs refer to potentially traumatic events occurring before age 18, including experiences like the death of a loved one, witnessing substance abuse or mental illness in the home, experiencing physical or sexual abuse or neglect, or living through a parent's divorce or incarceration.

The statistics are striking. In a survey of approximately 200,000 participants across 23 states between 2011 and 2014, 64% of people had experienced at least one ACE by age 18. About 17.3% had four or more, and 7.6% had five or more (Giano et al., 2020). A child with four or more ACEs is 12 times more likely to attempt suicide and 3.7 times more likely to experience anxiety in adulthood.

I want to note that these statistics are pre-COVID. Research emerging since the pandemic indicates that ACE scores have increased significantly across populations. The anxiety, the financial and food insecurity, the disruptions to routine and relationships, the losses, all of those are ACEs. When practitioners report that trauma feels uncommon in their caseloads, I always gently push back. Financial insecurity is an ACE. Food insecurity is an ACE. The feeling of failure in school is, in my view, a form of trauma. I think we are encountering it far more frequently than our intake forms reveal.

Trauma Versus PTSD

One of the most important distinctions to understand is that not everyone experiencing trauma symptoms will carry a PTSD diagnosis. PTSD was added to the DSM-III in 1980 and has been debated and revised ever since. The core controversy centers on Criterion A, which attempts to define what qualifies as a traumatic stressor. That definition has shifted substantially from DSM-III to DSM-5, expanding to include witnessing events, learning about events that happened to others, and experiencing repeated indirect exposure, such as first responders encountering details of child abuse.

The individualized nature of trauma is exactly what makes it so difficult to fit into a diagnostic hierarchy. And this is my central point: trauma-informed care should function the way universal precautions work in infection control. We should not wait for a PTSD label to apply a trauma-sensitive lens. Just as we don gloves before a procedure regardless of known infection status, we should hold trauma awareness as a baseline orientation with every client, in every setting.

What Counts as Trauma in Our Caseloads

When I talk to practitioners about trauma, the examples they tend to reach for are the obvious ones: abuse, neglect, loss. And yes, those absolutely belong on the list. But I want to expand the frame considerably, because I think there are many experiences that shape the children we work with that we are not currently naming as trauma.

Medical complications, for example. Think about children who have spent significant time in medical settings early in life, connected to monitoring equipment, helmets, G-tubes, oxygen, or stomas. These children experienced restricted movement and limited opportunities for climbing, spinning, and sensory exploration at a time when those experiences are neurologically critical. Their vestibular development, their core strength, their balance, their endurance, all of it was shaped by that constrained early environment. That is a form of developmental trauma, even if no one would describe it as such.

Muscle tone challenges and tongue ties are not trauma in the traditional sense, but they create disruptions in everyday function. When feeding and eating are painful or frustrating from the earliest months of life, the anxiety around those experiences can absolutely develop into something that looks and functions like trauma. The dread of mealtimes. The avoidance. The family stress. All of that matters.

I think frequently about ADHD and autism and the trauma these children experience simply as a result of living in environments that are not built for how their nervous systems work. The daily experience of not fitting in, of being labeled the disruptive kid, of failing at tasks that seem effortless for peers, accumulates into something that functions like trauma regardless of its cause. I have worked with children who, when I explained that their handwriting difficulty was related to a motor processing issue rather than effort or character, looked at me as though no one had ever said anything so freeing to them. Why hasn't anyone told me that before? Why hasn't anyone told me I am not just a bad kid?

Environmental factors, including unsafe or inconsistent living environments, limited access to movement and exploration, and community-level stressors all belong in our clinical thinking. Traumatic brain injury, including lower-level injuries and concussions that may not rise to the threshold for an MRI, can significantly impact executive functioning, motor skills, and participation. I worked with a child whose behavioral and developmental presentation was puzzling across disciplines, and when an MRI was eventually obtained, it accounted for everything our team had been observing. We do not always have access to that imaging. But we should be considering the possibility of unidentified brain injury in children whose profiles are unexplained.

How Trauma Impacts the Brain

Structural Changes

The neurological impact of trauma is visible in brain structure. Research by Jeong et al. (2021) has documented several consistent findings. Children with significant trauma histories show thinner cortex in the bilateral superior frontal gyri, regions associated with working memory and executive functioning, and in the right caudal middle frontal gyrus, which is tied to attention. They show a thicker cortex in the left posterior cingulate, which relates to alexithymia, and in the left isthmus cingulate, involved in emotional processing, cognition, and memory. They also show reduced gray matter volume in the right amygdala, our threat detector and emotional control center, and in the right putamen, which governs motor control and learning.

I want to flag alexithymia specifically because I had previously encountered that term almost exclusively in the autism literature. Finding it tied to trauma as well was striking to me. Many of the children I work with have significant difficulty identifying and labeling their own internal states. When I see that in a child with a trauma history, I now think about it differently. It is not just a feature of their neurodivergent diagnosis. It may be shaped by their experiences.

We also know that the structural differences vary depending on when the trauma occurred. Children who experience trauma at a very young age tend to show larger and more noticeable neurological effects than those who experience it in adolescence. This brings us back, again, to the urgency of early identification and early support.

Perceived Safety and the Threat Detection System

One of the most clinically useful concepts in trauma-informed practice is the idea of perceived safety. We are neurologically wired for safety. After trauma, however, the brain learns to detect both interoceptive and exteroceptive stimuli that resemble previous threats. As Lanius et al. (2025) describe, the traumatized individual is left unsure of what it feels like to feel safe (p. 33).

This distinction between actual and perceived threats is significant in clinical practice. A child may go into fight-or-flight when the math worksheet comes out. From the outside, there is nothing threatening about a math worksheet. But the child's brain and body have been wired to associate certain internal signals, a rising heart rate, muscle tension, and the flush of adrenaline, with danger. When those signals arise for any reason, the brain interprets them as a threat. It is not a choice. It is not misbehavior. It is the nervous system doing exactly what it was shaped to do to survive.

These children are also often in a state of hypervigilance. They are scanning the environment constantly for potential threats. They may look like they are not paying attention, but they are paying attention to everything. What they are not doing is focused attending, because their survival system will not allow it.

We can clearly frame this for families and educators: it is the child's perceived safety that governs their access to learning, not their intelligence, not their effort, and not their compliance.

The Three-Level Brain Model

Many practitioners are familiar with the triune brain model, which frames brain function across three levels: the brainstem, which governs fight-or-flight and automatic physiological functions; the limbic system, our threat detector, which monitors for belonging and danger; and the cortex, which houses our higher-level thinking, planning, empathy, and executive function.

For children who have experienced trauma, the limbic system is often running at a high level of activation. I tell parents and teachers: when a child says things like you always say no to me, that is often limbic language. That is a child operating from a sense of threat and disconnection, not from a place of rational evaluation. And here is the clinical implication: we cannot access higher-level thinking from within the limbic system. We cannot teach executive functioning, academic skills, cause-and-effect reasoning, or self-advocacy to a child who is running in threat-detection mode. We have to get the child regulated first.

This is one of the clearest areas where occupational therapy has a clinical advantage. We begin at the bottom. Movement, sensory input, interoception, self-regulation: these are the tools of our trade. We meet children where their nervous systems are and work upward. That is not an accident of our training. That is a core competency, and I think we need to advocate more loudly for its centrality to outcomes.

Hans Selye's General Adaptation Syndrome and the Defense Cascade

Hans Selye's General Adaptation Syndrome (1950) gives us a useful framework for understanding how the body responds to sustained stress. In the alarm phase, an acute stressor triggers an automatic fight-or-flight response. Once the threat passes, the body returns to baseline. This is a normal, healthy response.

When stress is sustained, the body enters a resistance stage, characterized by poor concentration, irritability, and frustration. These are the children whose behavior puzzles us because they seem fine in some moments and dysregulated in others. If the stress continues, the body eventually enters an exhaustion stage, where the parasympathetic nervous system is dominant, and the child may appear shut down, disengaged, or flat.

The Defense Cascade Model, which expands on Selye's work, helps us understand this continuum more precisely. Some children in an exhausted state may actually seek excessive movement, not because they are hyperactive in the traditional sense, but because they are trying to alert their nervous system. When we understand that, our intervention approach changes significantly.

Implications for Therapy

What We See in the Therapy Setting

Difficulty accessing and participating in the environment results in behaviors. Let me be specific about what that looks like in practice, because these are the presentations we encounter every day.

We see a lack of engagement or withdrawal, which we associate with freeze. We see demand avoidance, which is flight. We see explosive behaviors, which is fight. And we see loss of self or people-pleasing, which is fawn. Research confirms that school-aged children with elevated sensory over-responsivity exhibit higher levels of internalizing, externalizing, and dysregulation (Ben-Sasson et al., 2009; Leroux et al., 2023). Children who do not feel safe because of how their bodies feel will produce behaviors. That is not a discipline problem. That is a nervous system communicating the only way it knows how.

I also want to name the gender-based differences in how these presentations get labeled. Research tells us that girls with trauma histories are more likely to be identified with PTSD, while boys are more likely to carry a diagnosis of ADHD or conduct disorder (Leroux et al., 2023). The underlying experience may be similar, but the diagnostic framing diverges significantly. That has real implications for which services are recommended and which lens practitioners apply.

The Importance of Early Sensory Experience

Babies have no language. This is not a small point. In those earliest months, sensory experience is memory. The limbic system is wired through touch, movement, sound, smell, and the relational attunement of a caregiver. When those early sensory experiences are consistent, safe, and regulating, the nervous system learns what safety feels like. When they are not, the nervous system learns something else entirely.

This is why the NICU is worth naming as a potentially traumatic environment, not because the NICU does anything wrong, but because children in that setting often spend weeks or months separated from skin-to-skin contact, limited in their movement, overstimulated by medical equipment, and sometimes unable to be held. The children I see who have come through the NICU frequently show differences in proprioceptive and tactile awareness that trace directly to those early experiences.

And for children in environments of poverty or chronic income insecurity, research has documented decreased vocabulary, reduced foundational literacy skills, decreased comprehension, and challenges with print concept and writing composition, with many of these differences appearing as early as infancy (Allee-Herndon et al., 2022). Some researchers believe that by kindergarten, the developmental gap is already too large to close easily. These are not failures of individual children. These are the fingerprints of early adversity on developing nervous systems.

Trauma or Sensory? Does It Matter?

I get asked this question fairly regularly, and my answer is: clinically, it often does not matter as much as we think it does. Trauma presents much like sensory modulation variations, especially in terms of responsiveness to sensory stimuli (Joseph et al., 2022). A child who has experienced abuse or neglect in a noisy, unpredictable environment will frequently present with noise sensitivities that look essentially identical to what we would see in a child with sensory over-responsivity from a purely neurological standpoint. The strategies that help in both cases are remarkably similar.

What matters is that we understand the child's nervous system is responding to real signals, whether from developmental or experiential sources, or both. The dysregulation cycle is a four-step process: sensory information comes in, the brain processes it, a message is sent to the body, and a physiological change occurs. Trauma shapes how that cycle runs. Our job is to intervene at points within that cycle to support regulation.

Play as a Therapeutic Medium

Play is not just about how children have fun. It is how they develop. It is rich in language, cognition, social integration, social communication, and emotional regulation. Children have an innate desire to engage in play. It is internally reinforcing in a way that few other activities are. And critically, play can be used to shift a child's attention and change the state of the nervous system.

Chronic disease and chronic stress can be addressed through play (Nijhof et al., 2018). Parents' views on play significantly shape children's play experiences (Dhas et al., 2022). When families or educators dismiss play as non-essential, they are inadvertently removing one of the most powerful regulatory and developmental tools available to children. As OTs, play is central to how we work. That is not arbitrary. It reflects a deep understanding of what shifts the nervous system toward safety and engagement.

Interventions: Sensory Strategies and the Core Four

Sensory Strategies for Regulation

If we return to our three-level brain model, our therapy goals live in the cortex, in those higher-level functions. In order to access that zone, children need to feel safe. Sensory strategies are among our most powerful tools for creating a felt sense of safety.

Utilizing 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). When sensory information comes in at a level the nervous system can process, and it does not send the threat detector into overdrive, we create the conditions for learning.

Proprioceptive input, in particular, has a well-established relationship with emotional regulation and de-escalation. Proprioceptive input elicits the production of serotonin and dopamine, two neurotransmitters responsible for the regulation of the central nervous system (Collins and Dworkin, 2011). When we are giving muscles and joints meaningful input, whether through heavy work, resistance, carrying, pushing, or pulling, we are directly supporting the neurochemistry of regulation. This is not incidental to our practice. This is the mechanism.

The Core Four

Over years of clinical practice, I have identified four sensory inputs that I return to consistently for supporting regulation in children who have experienced trauma. I call them the Core Four: rhythm, deep pressure, vibration, and breathing.

I use these interchangeably and embed them within play whenever possible. Rhythm provides predictability, which is one of the most regulating experiences available to a dysregulated nervous system. Deep pressure, through weighted items, resistance, compression, or firm touch, activates proprioceptive pathways and supports a calm neurochemical environment. Vibration is deeply regulating for many children, particularly through the trunk and core. And breathing, specifically slow, controlled, extended exhalation, directly engages the parasympathetic nervous system.

None of these is complicated. All of them can be embedded in play, in daily routines, in classroom transitions. And for children whose nervous systems have been shaped by early adversity, these four inputs can be the difference between a session in which learning happens and one in which it does not.

Conclusion

Trauma-informed practice is not a specialty area for a subset of OTPs working in specialized settings. It is a foundational lens that belongs in every practitioner's toolkit, across every population and every setting. The children we serve bring with them a history we may never fully know. What we do know is that their nervous systems are shaped by that history, and our interventions need to meet them where they are.

We have explored how typical development provides the foundation on which trauma either builds or disrupts, how the brain responds structurally and functionally to early adversity, and what that means for the children sitting in front of us every day in schools, clinics, homes, and hospitals. We have looked at why perceived safety governs access to learning far more powerfully than effort or instruction. And we have walked through a set of evidence-informed, sensory-based strategies, including the Core Four, that can support regulation as the foundation for every other goal we pursue.

I want to leave you with this: telling a child to try harder is not an intervention. Understanding how their brain functions and meeting it where it is, that is an intervention. Occupational therapy practitioners are uniquely positioned to do this work. We start at the bottom. We work with the body. We use play, movement, and sensory experiences to create conditions that support brain growth. That is not a soft skill. That is our clinical expertise, and children who have experienced trauma need it now more than ever.

References

See additional handout.