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Working with Children Exhibiting Difficult Behaviors: 6 Tips for OTPs

Working with Children Exhibiting Difficult Behaviors: 6 Tips for OTPs
Elisabeth Bahr, OTD, MS, OT/L
November 14, 2023

A young child sitting with their head between their hands

Working with children with challenging behaviors can be a rewarding yet daunting experience for OTPs. Even with the most meticulously crafted treatment program, you might face unforeseen challenges during sessions.

Both adults and children rely heavily on their self-regulation and co-regulation abilities to manage daily difficulties. 

For some children, unexpected triggers (e.g., a fire drill, an intimidating task) can evoke intense reactions and even meltdowns. Challenging behaviors add additional complexity to our best efforts and can even lead to stress and burnout. 

One principle remains constant amid this uncertainty: Every child merits a sense of belonging, including when working with their occupational therapist.

Below are strategies to assist pediatric OTPs in navigating the difficulties of working with children who exhibit challenging behaviors:

1. Preparation Ahead of an OT Session

A pediatric OTP knows that therapeutic use of self is invaluable during sessions. Our youngest clients rely on their OT for co-regulation and for instruction in self-regulation. For an OT to effectively lead a child toward self-regulation, the therapist must embody it. Prepare before sessions with deep breathing, guided relaxation, or journaling. A consistent morning routine that allows time before sessions can help establish this foundation.

2. Consider the Environment

An organized, decluttered space reduces potential distractions. Define tasks, their lengths, and anticipated results. Offering a clear plan can help diminish anxiety before the session. Ensure tools are within reach, and integrate visual aids to clarify tasks and expectations.  

3. Build on the Child's Strengths

The OTP can gather information about a child's preferred learning method and collaborate with the classroom team to optimize learning strategies. 

A strength-based approach is helpful for building on a child's innate strengths and utilizes them as foundational pillars for continuous progress and growth. 

4. Distinguish Behavior from Identity

When a child acts disruptive, it is often an attempt at communication and a call for empathy. What is the child trying to tell you about their internal state? What needs aren’t being met? 

OTPs can play a role in investigating underlying causes for behaviors. Identify whether avoidance, attention-seeking, sensory needs, or tangible rewards drive behaviors. 

Keeping a diary of triggers can help set up sessions and the environment for therapy.

5. Promote Self-Awareness Among OTPs

Continuous self-assessment enables OTPs to grow professionally and personally. After a challenging session, take a few moments to identify what went wrong and what went right during the session. Identify and address any underlying biases or emotions that might affect interactions. 

Self-awareness is an essential skill for OTPs to develop and use to enhance their professional practice.

6. Recognize the Need for Decompression

Pediatric OTPs often find themselves balancing on a delicate line. They share in the joys of breakthroughs and the challenges of setbacks. As rewarding as this work may be, it can also be draining.

As healthcare workers, the reality of compassion fatigue and burnout cannot be overlooked.

OTPs can engage with peers for support, utilize techniques to prevent rumination, and prioritize professional and personal self-care. 


Every challenging behavior signifies a plea for empathy and understanding. These behaviors should not be interpreted as a definition of the child but rather as indicators of underlying unmet needs. The mission of a pediatric occupational therapist is to illuminate these children's strengths and guide them toward growth. 

More on this topic can be found in this OccupationalTherapy.com course

elisabeth bahr

Elisabeth Bahr, OTD, MS, OT/L

Elisabeth Bahr is a writer, artist, and occupational therapist. She holds a master of science from NYU and a doctorate in occupational therapy from BU. She is currently a health writer, educator, and advocate. You can find her consulting work at pegasuswellness.co and her writing on Continued and around the internet.

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