Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth

Childhood Trauma
Did you know… OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to promote physical
and mental health and well-being. Occupational therapy practitioners focus on participation in
A report of a child abuse is made the following areas: education, play and leisure, social activities, activities of daily living (ADLs;
every 10 seconds (Childhelp, n.d.).
e.g., eating, dressing, hygiene), instrumental ADLs (IADLs; e.g., preparing meals or cleaning up,
caring for pets), sleep and rest, and work. These are the usual occupations of childhood. Task
Occupational Performance analysis is used to identify factors (e.g., motor, social–emotional, cognitive, sensory) that may
Children who experience trauma may be challenged in limit successful participation across various settings, such as school, home, and community.
the following ways: Occupational therapy practitioners offer activities and accommodations within their service to
Social Participation promote successful performance in these settings.
• Impaired social skills
• Increased depression, anxiety, and emotional
numbing WHAT IS CHILDHOOD TRAUMA?
• Over activated traumatic stress response Childhood trauma is a psychologically distressing event involving “exposure to actual or threat-
• Poor interpersonal boundaries
ened death, serious injury, or sexual violence…” (American Psychiatric Association, 2013, p. 261).
• Fear of failure/hyperawareness of possible failure,
leading to decreased participation in activities Such events involve a sense of fear, helplessness, and horror. Childhood trauma occurs whenever
• ADL deficiencies (listed below) that can lead to both internal and external resources are inadequate to cope with an external threat (van der Kolk,
difficulty interacting with peers (e.g., being teased
1989). Children may experience trauma from abuse (physical, sexual, emotional), neglect (physi-
about poor hygiene)
• History of isolation and lack of opportunity to cal, medical, emotional, educational), natural disasters, illness, and violence (school, community,
interact with others domestic).
Activities of Daily Living Trauma exposure activates fight, flight, or freeze stress reactions, the human response to
• Diminished motivation to complete daily routines
• Difficulty managing hygiene
experiences of overwhelming stress. Most children exposed to an isolated traumatic event will
• Difficulty controlling bladder and bowel for toileting recover in time. However, exposure to chronic interpersonal trauma (i.e., child maltreatment)
• Trouble eating (e.g., food hoarding behaviors) results in complex trauma, a condition that adversely affects virtually every aspect of develop-
• Lack of exposure to direct instruction on how to
complete ADLs such as hygiene
ment. Complex trauma in childhood is termed developmental trauma (van der Kolk, 2005), a
• Fear of ADLs; abuse and neglect are frequently as- condition that presents with significantly higher levels of dysregulation (affective, physiological,
sociated with locations where ADLs are completed attentional, behavioral, and relational), functional impairments, and psychiatric hospitalizations
(e.g., bedroom, shower/bathroom)
compared with children with posttraumatic stress disorder and histories of “non-violent” trauma
Education
• Impaired executive function (Kisiel et al., 2014).
• Difficulty envisioning a future (Bloom & Yanosy- More than 3 million cases of child abuse and neglect are reported in the U.S. each year (U.S.
Sreedhar, 2008) Department of Health and Human Services [HHS], 2013) In 2013, the national rate of reported
• Impaired attention and arousal regulation
• Negative attention seeking child abuse and neglect was 28.3 per 1,000 children in the national population (HHS). Because
• Poor attendance and homework completion occupational therapy practitioners serve young children in homes, schools, and communities,
• Staff or teacher not understanding the reason for they have a significant role in (1) recognizing the signs of trauma; (2) creating safe environments
negative behaviors (“What is wrong with him?” vs.
“What happened to him?”) that support learning and development; (3) with advanced training, treating children who have
Work experienced trauma; (4) collaborating to model and facilitate skills for managing emotions for
• Difficulty attaining and maintaining employment the adults who serve children who are survivors of trauma; and (5) with advanced training, col-
(Bloom & Yanosy-Sreedhar, 2008)
laborating with children who are survivors of trauma and the adults who serve them to develop
• Lack of insight with how poor self-care (e.g.,
hygiene) and social skills impact ability to be suc- skills and techniques to safely and proactively avoid crises, and to develop reactive strategies to
cessfully employed safely work through crisis situations to minimize additional trauma.
• Difficulty managing emotions to successfully
navigate stressful situations
Play/Leisure
WHAT IS TRAUMA-INFORMED CARE (TIC)?
• Decreased initiation in play and healthy leisure According to the National Child Traumatic Stress Network (n.d.), a trauma-informed care per-
activities spective is one in which program staff, agency staff, and service providers (1) routinely screen for
• Over-aggressive play and bullying trauma exposure and related symptoms; (2) use culturally appropriate evidence-based assess-
• Frequent fear of failure and withdrawing from activi-
ties (e.g., “I quit!”) ment and treatment; (3) make resources available to children, families, and providers on trauma
Sleep/Rest exposure, its impact, and treatment; (4) engage in efforts to strengthen the resilience and protec-
• Difficulty falling and staying asleep (Humphreys, tive factors of children and families impacted by and vulnerable to trauma; (5) address parent
Lowe, & Williams, 2009)
• Increased occurrence of nightmares and sleep
and caregiver trauma and its impact on the family system; (6) emphasize continuity of care and
disturbances (Caldwell & Redeker, 2005) collaboration across systems; and (7) maintain an environment of care for staff that addresses,
• Increased bed wetting (Humphreys et al., 2009) minimizes, and treats secondary traumatic stress, and that increases staff resilience.

This information was prepared by Terry Petrenchik, PhD,

OTR/L, and David Weiss, OTR/L, with contributions from
AOTA’s 2015 School Mental Health Workgroup.

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx

 Occupational Therapy’s Role in Addressing Childhood Trauma
OCCUPATIONAL THERAPY’S ROLE IN ADDRESSING CHILDHOOD TRAUMA
Occupational therapy practitioners can serve an important role in addressing trauma at the universal, targeted, or intensive levels of interven-
tion. They are invaluable members of the mental health team because of their knowledge of the cognitive, social and emotional, and sensory
components of activity and its impact on behavior (Petrenchik, 2015; Petrenchik & Guarino, 2009).
Children who have experienced complex trauma need environments and opportunities to regain a sense of personal safety, competence,
and pleasurable connection to others. Safety, predictability, and “fun” are essential ingredients for helping a child to be “in the moment”
where all learning, skill development, and healing happen (van der Kolk, 2005). Because occupational therapy practitioners have specialized
training in task analysis and environmental modification, they can optimize the child-environment-occupation fit to enable successful activ-
ity engagement and social participation.
Traumatized children have difficulties handling emotions, sensations, stress, and daily routines. They often feel hopeless, worthless, and
incompetent (van der Kolk, 2005). Occupational therapy practitioners work with other disci-
plines to structure environments, teach cognitive strategies, and develop social and emotional
skills that promote self-regulation, competence development, trust building and confidence, and
Occupation-based strategies could
resilience through participation.
include:
Promotion • Making activities and routines
• Raise awareness about the occurrence and impact of child trauma. predictable
• Create a culture of nonviolence through promoting positive behaviors. • Helping children regain control by
• Foster children’s interests in healthy and safe play and leisure occupations. allowing for choice within activities
• Teach children positive coping skills, relational skills, and problem-solving skills.
• Pairing sensory approaches with
• Model and teach staff and adults who serve survivors of trauma principles of emotional regu-
cognitive approaches to teach
lation and co-regulation. children to calm their bodies and
minds
Prevention
• Recognize signs and symptoms of trauma. • Providing frequent positive
• Provide group-based interventions focused on self-regulation and sensory modulation, as reinforcements
well as self-efficacy. • Recommending stress
• Use self-awareness techniques to teach children emotional regulation strategies (see The management strategies
Zones of Regulation in Check This Out!).
• Collaborating with clients to identify
• Educate parents and teachers about healthy discipline, including the use of positive behavioral goals and interventions designed
supports and ways to effectively deal with crises. to empower

Intensive • Providing frequent direct

Occupational therapists with training in trauma and sensory-based interventions are qualified to: instruction and modeling to create
ongoing competence and success
• Provide trauma-informed sensorimotor arousal regulation interventions in collaboration
with mental health professionals (see LeBel & Champagne, 2010; Warner, Spinazzola, West- • Collaborating and modeling
cott, Gunn & Hodgdon, 2014;). emotional management strategies
• Teach children mindfulness strategies to reduce stress and to cope with overwhelming emo- consistently among the staff,
tions. teachers, and other adults
• Provide environments and opportunities intentionally designed to increase a traumatized
child’s sense of mastery, connection, and resiliency (see Treating Traumatic Stress in Children
and Adolescents in Check This Out!). Did you know Massachusetts has
• Provide opportunities for play and social interaction to facilitate the development of likes, adopted an initiative that includes
sensory interventions to help reduce
interests, and motivators.
restraints? For more information on
the occupational therapist’s role in
IN THE HOME, occupational therapy practitioners work with caregivers to create predictable embedding sensory interventions
routines. Children who experience trauma often feel out of control. Practitioners provide opportu- into agencies that provide services
nities in the home that are predictable and routinized, and that allow the children to have a sense of for children who have experienced
control. They can also create structured daily routines, promote safe family activities, and support trauma, see: http://www.aota.
self-regulation, including addressing sleep and eating issues. org/-/media/Corporate/Files/
Children who experienced trauma in early childhood often have difficulty developing healthy Secure/Publications/SIS-
attachments to caregivers. Occupational therapy practitioners who understand attachment theory Quarterly-Newsletters/MH/MHSIS_
work with caregivers to create a healthy attachment and encourage bonding through developmen- June_2010.pdf
tally appropriate childhood occupations (see Circle of Security International in Check This Out!).

This information was prepared by Terry Petrenchik, PhD,

OTR/L, and David Weiss, OTR/L, with contributions from
AOTA’s 2015 School Mental Health Workgroup.

Copyright © 2015 by The American Occupational Therapy Association, Inc.

 Occupational Therapy’s Role in Addressing Childhood Trauma

CHECK THIS OUT!

IN SCHOOL, occupational therapy practitioners promote social interactions among peers and
support the teachers to create a safe and nurturing environment that enhances learning. They • The National Child Traumatic
help educators and staff understand the impact of trauma on learning and identify supports, Stress Network www.nctsn.org
create an environment that promotes self-regulation and predictability, and help establish an • Child Trauma Academy
environment to secure the child’s trust. childtrauma.org

IN THE COMMUNITY, occupational therapy practitioners have a role in promoting healthy • The Adverse Childhood
Experience Study
activities. They help facilitate successful community outings and instruction that support friend-
www.acestudy.org
ships and a sense of safety, and foster development in children who have experienced trauma.
Occupational therapy practitioners may also collaborate with and provide services at organiza- • Child Welfare Information
tions, such as community-treatment centers, group homes or residential facilities, and foster care Gateway. What is Child Abuse
agencies. and Neglect? Recognizing
Signs and Symptoms https://
www.childwelfare.gov/pubs/
factsheets/whatiscan.pdf
• Information on occupational
therapy approaches www.OT-
innovations.com
• American Academy of
Pediatrics Trauma Guide www.
aap.org/en-us/advocacy-and-
policy/aap-health-initiatives/
healthy-foster-care-america/
Pages/Trauma-Guide.aspx
• National Center for Trauma-
Informed Care and Alternatives
to Seclusion and Restraint
(NCTIC) www.samhsa.gov/
nctic
• Circle of Security International
circleofsecurity.net
• Book: Treating Traumatic Stress
in Children and Adolescents:
How to Foster Resilience
Through Attachment, Self-
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and statistical manual of mental disorders (5th ed.). sensory and trauma-informed interventions: A by Margaret Blaustein & Kristine
Washington, DC: Author. Massachusetts state initiative, Part 2. Mental Health Kinniburgh.
Bloom, S. L., & Yanosy-Sreedhar, S. (2008). The sanctuary Special Interest Section Quarterly, 33(2), 1–4.
• The Zones of Regulation:
model of trauma-informed organizational change. National Child Traumatic Stress Network (n.d.). What is
Reclaiming Children & Youth, 17(3), 48–53. a trauma-informed child and family service system?
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van der Kolk, B. A. (1989). The compulsion to repeat the
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www.aota.org