Moving Together: Polyvagal Perspectives on Co-Regulation in Paediatric OT

In paediatric occupational therapy, the activities we might plan to do —fine motor tasks, sensory play, executive function scaffolds—are only part of the picture. Behind every session lies an even deeper layer: the nervous system states of the child, and our own. It's what we do with that, where the magic lies.

Polyvagal Theory, developed by Dr Stephen Porges, helps us understand these states. It gives us a powerful lens through which to reframe client behaviour—not as compliance or defiance, but as expressions of safety or threat. And when we begin to see therapy as a nervous system-to-nervous system experience, one truth becomes clear:

We must learn to move with our clients—physically, emotionally, and relationally—if we want to support lasting growth.

Understanding Polyvagal Theory in Practice

At its core, Polyvagal Theory maps three primary states of the autonomic nervous system:

1. Ventral Vagal (Social Engagement) – The “safe and connected” state. Children are open, curious, able to play and learn.

2. Sympathetic Activation (Mobilisation) – The “fight or flight” state. Energy surges. Focus narrows. Movement increases.

3. Dorsal Vagal (Shutdown) – The “freeze/collapse” state. A child may become withdrawn, shut down, or emotionally flat.

   
   

   

IMPORTANT NOTE: Children may move fluidly between these states across a session. As therapists, our job is to attune to their nervous system state—not just the behaviour we see—and adapt accordingly. That’s what it means to move with the client.

Moving with the Child: What It Looks Like

"Moving with" doesn't always mean physical movement—though it often includes it. It means noticing the child’s physiological and emotional cues and adjusting our pace, tone, proximity, activity, or expectations to match where they are, and gently guide them toward a state of safety and connection.

It might look like:

• Lowering your body to the floor when a child curls up under the table

• Mirroring a child's rhythm of play before introducing a new task

• Joining their sensory movement rather than trying to stop it

• Offering choices and predictability when the child’s system shows threat responses

  
  

Different Diagnoses, Different Needs

Polyvagal-informed practice reminds us that there is no one-size-fits-all response. Children with different neurodevelopmental profiles show different nervous system patterns and different pathways to regulation.

Autism Spectrum Disorder (ASD)

Autistic children often live with a heightened baseline of sympathetic activation due to sensory sensitivities, unpredictable environments, and difficulties with social-emotional cues. Moving with these clients means respecting their sensory needs, offering co-regulation instead of forced eye contact, and adjusting demands based on subtle cues (e.g., jaw clenching, body tension, withdrawal).

Example: If a child is flapping or pacing, instead of stopping the behaviour, the therapist may join with parallel movement and slowly introduce a transition when the child shows readiness.

ADHD

Children with ADHD may enter sessions already in sympathetic drive—buzzing with energy, darting attention, or sensory seeking. Instead of demanding stillness to “get started,” moving with these clients might mean beginning sessions with heavy work or movement breaks, using rhythm to support regulation, and scaffolding attention in small, doable bursts.

Example: A therapist might play catch while asking reflective questions, or do handwriting practice while bouncing on a therapy ball.

Trauma Histories

Children with trauma backgrounds often shift rapidly between states, and their neuroception (the nervous system’s detection of threat or safety) may be skewed. These children may interpret even gentle correction or transitions as danger.

Moving with them means slowing down, softening your voice, narrating your actions, and building a deep sense of predictability and safety. Power struggles are particularly triggering, so offering choices and seeking consent is critical.

Example: A child refuses to engage in an activity. Instead of insisting, the therapist might sit quietly nearby and say, “I’ll be right here if you want to show me something different.”

Global Developmental Delay or Intellectual Disability

Children with cognitive delays may show limited verbal communication, which means their nervous system signals (behaviour, gesture, tone) are even more important to read. Moving with them often includes adjusting to their processing pace, using visual supports, and offering repetition and rhythm.

Example: If a child resists an unfamiliar task, the therapist can model it at a slower pace, using gestures or song, to invite curiosity and engagement.

What Happens When We Don’t Move with the Child?

When we ignore the child’s nervous system state, we risk inadvertently pushing them further into threat responses. They may:

• Resist or avoid task demands

• Meltdown or shut down

• Withdraw trust in the therapeutic relationship

• Associate therapy with failure, fear, or shame

Over time, we may see reduced participation, increased dysregulation, or learned helplessness. Conversely, when we honour the nervous system, we foster safety, agency, and the conditions for real change.

Co-Regulation is Our First Modality

No activity, game, or goal matters more than the state the child is in—and the state we bring to them. When we are calm, regulated, and attuned, we offer a powerful co-regulatory anchor. When we move with the child, we send the message:

 “You are not too much.”

“You are safe with me.”

“We’ll go at your pace.”

And that’s where therapeutic progress can begin.

Polyvagal Theory teaches us that safety is the gateway to connection, learning, and growth. As paediatric occupational therapists, our first job is to see the nervous system beneath the behaviour—and respond with attunement, flexibility, and compassion.

Moving with the client isn’t stepping back from the work.

It is the work.