In recent years, the understanding of trauma and its profound impact on development and daily functioning has grown significantly. For children, early adverse experiences can disrupt neurodevelopment, hinder skill acquisition, and affect their ability to engage in daily activities. Given these challenges, there is a pressing need for specialized approaches within therapeutic fields to address the complex effects of trauma. This is where trauma-informed occupational therapy (TIOT) comes into play.
In 2020, I produced a Trauma-Informed Practice Protocol made specifically for pediatric occupational therapy practioners as part of my doctoral project. Occupational therapy practitioners are uniquely positioned to support children who have experienced trauma. By integrating principles of trauma-informed care, occupational therapists can create safe, supportive environments and tailor interventions to meet the specific needs of these children. This approach not only addresses the immediate effects of trauma but also fosters resilience and promotes long-term well-being.
This excerpt explores the foundations and applications of trauma-informed occupational therapy, highlighting the importance of understanding adverse childhood experiences (ACEs) and their impact on development. It also introduces the start of the Trauma-Informed Practice Protocol designed for pediatric occupational therapy practitioners, which provides evidence-based strategies for evaluation, intervention, and creating trauma-sensitive environments. By delving into the role of occupational therapy in addressing trauma, this article aims to equip practitioners with the knowledge and tools needed to enhance the care and support of children who have faced early adversity.
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As many as two-thirds of youth are at-risk for experiencing adversity which can have lifelong effects on health outcomes (Felitti et al., 1998). Furthermore, researchers of multiple studies have demonstrated that early exposure to adversity has the potential to globally impact occupational performance (Bethell et al., 2014; Blodgett & Lanigan, 2018; Jimenez et al., 2016; Plumb et al., 2016). The significant impact of adversity on human development and participation in daily activities highlights the importance of providing trauma-informed services for children.
The purpose of the Trauma-Informed Practice Protocol is to provide an evidenced-based resource for occupational therapy practitioners to utilize when working with children who have experienced early adversity. While occupational therapy practitioners have knowledge of activity analysis and occupational performance, this protocol applies and explains the clinical reasoning behind trauma-informed care in pediatric therapy. In the Trauma-Informed Practice Protocol, background information is discussed as well as strategies for evaluation, intervention, and creating a trauma-informed environment. Email me today if you would like access to the Trauma-Informed Practice Protocol.
Literature Review
In order to understand the impact of trauma on childhood occupations and occupational therapy’s role in trauma-informed service provision, the following constructs will be reviewed: adverse childhood experiences and trauma, how trauma impacts children, and the role of occupational therapy in addressing trauma.
Adverse Childhood Experiences and Trauma
Trauma is defined as witnessing or experiencing an adverse event that threatens the emotional or physical state of oneself or another (National Child Traumatic Stress Network, 2019). A common categorization for trauma is called adverse childhood experiences (ACEs), which are incidences of abuse, neglect, or household dysfunction that occur prior to the age of eighteen (Felitti et al., 1998). Other examples of potentially traumatic experiences include premature or difficult birth, NICU/PICU hospitalization, institutionalization, or acquisition of an injury or disease (Purvis et al., 2013).
As many as two-thirds of children have experienced at least one ACE, and those who have experienced an ACE are 81-98% more likely to have experienced another (Dong et al., 2004). The cumulative nature of ACEs is concerning as the risk of developing chronic health issues increases with the number of ACEs (Felitti et al., 1998). Additionally, youth with more ACEs are at higher risk for poor social, cognitive, and/or physical development (Becker-Weidman, 2009, Jimenz et al., 2016).
Impact of Trauma on Children
Various researchers have documented the effects of trauma on neurodevelopment, skill acquisition, and engagement in daily activities. Children may process trauma experiences on a sensory, preverbal level due to limited cognitive skill or awareness (Finn et al., 2018). Children with histories of traumatic experiences may have had fewer opportunities to engage in activities that lay the foundation for sensory system development. For example, a child who has undergone physical neglect may not have been picked up often, leading to decreased tactile, vestibular, and proprioceptive input. Another child may have been exposed to threatening experiences that are stored implicitly in the sensory system. This can lead to sensory processing deficits across the lifespan.
As a result, children with early experiences of adversity are more likely to have nervous system irregularities including increased sympathetic activity, neurotransmitter imbalances, and atypical sensory processing (Purvis et al., 2013; Perry, 2009). If a child is not exposed to appropriate tactile, proprioceptive, and vestibular input during the early formative years of life, he or she may develop inappropriate responses to typical environmental stimuli (Ayres, 2005; Lin et al., 2009). For example, a classroom filled with bright lights, multiple kids moving about the room, and various noises can be distracting and heighten the sympathetic nervous system. Additionally, the development of self-regulation can be disrupted if co-regulation is not established (Purvis et al., 2013). The variety of factors impacting neurobiological processes can make self-regulation, attending to tasks, and engaging in meaningful occupations difficult.
Along with the global effects of trauma on brain development, skill acquisition is impacted. Children with early adversity may have decreased exposure to enriching experiences or neurological imbalances that hinder skill development. As a result, participation in nearly every occupation can be impacted by the effects of trauma. For example, children with adverse experiences are less likely to develop positive peer relationships due to poor attachment styles or unrealistic ideals of social expectations (Purvis et al., 2013). Furthermore, ACEs are associated with decreased academic performance, poor social relationships, disrupted sleep patterns, maladaptive coping strategies, and increased behavioral problems limiting participation in meaningful activities (Blodgett & Lanigan, 2018; Bethell et al., 2014).
Role of Occupational Therapy in Addressing Trauma
Occupational therapy practitioners provide holistic interventions targeting factors in the person, the environment, and the occupation to improve performance and participation in occupations. As occupational therapy practitioners, service provision for children with adverse experiences should be linked to a person’s ability to engage in meaningful occupations successfully. Therefore, the role of the occupational therapy practitioner is to provide supports and interventions that target factors affected by trauma.
This can be done by utilizing a trauma-informed care approach. According to the Substance Abuse and Mental Health Administration (2018), a trauma-informed approach should include the following principles:
1) Realize that trauma has a widespread impact on individuals, families, groups, organizations, and communities and has an understanding of paths to recovery;
2) Able to recognize the signs and symptoms of trauma in clients, staff, and others in the system;
3) Integration of trauma knowledge into policies, programs, and practices;
4) Seeks to avoid re-traumatization (p. 1).
Understanding the extensive impact of trauma, recognizing the signs and symptoms of trauma, and integrating knowledge on trauma into practice can promote resilience and reduce risk of re-traumatization (Leitch, 2017). Therefore, occupational therapy practitioners working with children with histories of trauma should provide services using trauma-informed care. For an occupational therapy practitioner, using trauma-informed care does not necessarily mean treating trauma, but rather the impact trauma has on occupational performance. Furthermore, occupational therapy practitioners are some of the only licensed professionals that can touch clients in their scope of practice. Given the impact of trauma on sensory processing and relationships, this can be an essential factor for healing. It is within an occupational therapy practitioner’s scope of practice to address the underlying effects of trauma as it relates to occupational performance.