An OT perspective on the accumulative
effect of Historical Abuse

By Ms Antonette Owen, Team Lead Occupational Therapist, Benchmark ASSESS

The scale and consequences of historical child abuse in Australia have become increasingly visible since the 2013–2017 Royal Commission into Institutional Responses to Child Sexual Abuse[1]. As survivors continue to seek justice and redress, the legal system—and those who work within it—are being called upon to deepen their understanding of the complex, long-term impacts of trauma. This article explores the critical role that occupational therapy assessments can play in evaluating the functional and psychological effects of abuse over time. Drawing on an established occupational therapy practice model, we examine how trauma influences survivors’ daily functioning and capacity, and how this insight can support more informed legal and therapeutic responses.

Doing, Being, Becoming

In occupational therapy practice, the themes of Doing-Being-Becoming are described in a practice framework. In this framework, “Doing” refers to occupation and occupational performance of an individual, which is essential for the individual to interact with others and develop their own identity, and to create and shape the society in which they live, which would then become their frame of reference. “Being” refers to being true to self, where individuals are required to spend time thinking and reflecting upon themselves. This helps an individual describe and sustain their own roles. “Becoming” means how people redefine their values and rethink their priorities to prepare transformation of their new roles as they navigate life. This concept of becoming may change continuously over time, reflective of how a person sees his or her future. Further aspects of “becoming”, including becoming competent, and becoming a social being. All the of these “becoming” aspects hold the potential for growth and self-actualisation of the individual. It is thus suggested that occupational therapists help people by enabling them to do and to be, and through the process of becoming in clinical practice. The synthesis of doing, being, and becoming is integral to health and well-being of the individual who can achieve health through engaging in meaningful occupations.[2]

When an individual is subjected to institutional/historical abuse over time, it results in accumulative trauma which severely disrupts that individual’s ability to do meaningful daily occupations, such as work, school, or self-care, leading to a diminished sense of being (identity and self-worth) and a struggle with becoming (personal growth and future goals) due to fragmented self-perception and heightened anxiety. Occupational therapists can assess these impacts and address this by using trauma-informed strategies to help individuals regulate emotions, manage sensory sensitivities, improve motor skills, and re-engage in purposeful activities, which supports their recovery of identity and facilitates a positive path toward personal growth.

Impact on Doing

Trauma can cause disruption with an individual’s capacity to initiate and actively engage in everyday tasks, leading to difficulties in areas like self-care, school attendance or maintaining employment, and participating in constructive leisure and social activities. Limited opportunity to engage in occupational roles due to being in abuse related environments from a young age, where development of life skills might not have been conceptualised, can impact the young person’s ability to achieve normal developmental milestone which can ultimately lead to role deprivation.

Individuals who experience trauma, especially over a prolonged period such is the case with institutional abuse matters, often present with a constantly heightened sensory system focused on threat, which makes it difficult to focus on other activities and tasks. Repeated exposure to trauma can result in an individual presenting with a primitive response to threat, which is defined as automatic, innate defensive behaviour that activates the body’s survival mechanisms, including the fight or flight response, where you either confront or flee the danger. Other primitive threat responses include freezing (a temporary pause), flopping (collapsing in immobility), and fawning (appeasing the perceived threat). The individual who had experienced institutional abuse over a period of time, would become accustomed to operating from these primitive defences, which can present as difficulty making decision, becoming isolated, heightened anxiety, poor initiation, planning and completion of even basic tasks, etc.[3] [4]

Exposure to trauma, particularly from a young age, as often is the case when dealing with institutional abuse maters, can lead to psychomotor retardation, affecting how quickly a person moves and thinks. Traumatic experiences, especially in childhood, can lead to changes in brain chemistry and neurobiological responses. These changes, such as an imbalance in neurotransmitters like dopamine, are linked to the development of conditions that include psychomotor impairment. Childhood trauma has been identified as a risk factor for developing cognitive and psychomotor aspects of depression.[5] Therefore, trauma can impact fine and gross motor skills, making activities such as writing, dressing, or participating in sports more challenging. Complex trauma, particularly in childhood, can further alter brain development, leading to difficulties with self-regulation, emotional expression, and sensory processing, which can affect school and social functioning.

Impact on Being

To understand functional capacity, one first needs to understand what normal functional capacity means to an individual prior to the subject abuse/trauma, their usual routines, habits, and participation in life roles. However, what happens in the case where the subject abuse/trauma occurred at a young age, such as institutional and sexual abuse matters, where there is limited baseline functional capacity to refer to as the child was still in the process of developing their unique identity and exploring participation in various life roles?

Exposure to trauma can lead to a negative self-perception, with feelings of embarrassment, guilt, anger, or anxiety, resulting in a shift in who the individual perceives themselves to be, resulting in a fragmented identity. A diminished sense of purpose and struggle to perform daily activities can erode a person’s self-worth and sense of purpose. Difficulty managing emotions is common, leading to increased anxiety, fear, and volatile emotional states, further impacting a person’s sense of self due to poor emotional regulation. Survivors of institutional abuse often had a lack of positive role models during the crucial periods of their development, which can further impact their ability to develop healthy coping skills when having to deal with everyday problems and having to regulate their emotions.

Impact on Becoming

The overwhelming nature of trauma can hinder the individual’s personal growth and the ability to set and achieve future goals, as the person remains stuck in a state of survival, resulting in stunted growth and development. A sense of purpose and meaningful engagement in life can be lost when daily occupations are disrupted, making it hard to envision and move toward a desired future. Learning and engaging in new occupations, which are vital for personal growth and change, become difficult when a person is struggling with the effects of trauma, impacting their capacity to learn and develop new skills. Due to limited opportunity to develop healthy coping strategies from a young age, abuse survivors often engage in destructive coping strategies, such as making use of elicited drug use from a young age, impacting brain and emotional development, resulting in poor capacity for abstract reasoning and emotional insight.  Moving into adulthood, they often become trapped in varied perpetuating abuse cycles, continuing to engage in self-destructive behaviours.  Historical abuse can therefore increase the risk of mental health conditions and substance use disorders, which can further hinder a person’s engagement in meaningful occupations. The long-term effects of childhood adversity can manifest in adulthood as poor physical and mental health, as well as compromised parenting capabilities, affecting future generations.

Why an Occupational Therapy Assessment matters

Occupational therapists are uniquely positioned to understand typical developmental trajectories and to identify the disruptions that occur when trauma—such as childhood abuse—interferes with these processes. When developmental roles are interrupted, the resulting impact on an individual’s ability to function across various life domains can be profound. Occupational therapy assessments are instrumental in evaluating these effects, particularly in terms of functional capacity and occupational performance.

Through a holistic and client-centred approach, occupational therapists assess physical, cognitive, and psychosocial functioning, while also considering environmental and personal factors. This often includes evaluating individuals within their home and community settings, and taking into account cultural norms and lived experiences. Such comprehensive assessments provide a nuanced understanding of how trauma affects day-to-day functioning and performance skills.

By viewing the individual as a whole person—not just a collection of symptoms—occupational therapists are able to uncover the underlying reasons behind functional difficulties. This depth of insight supports the development of tailored interventions and ensures that all aspects of a person’s well-being are addressed, rather than focusing solely on isolated problems.

Components of the Occupational Therapy Assessment

An occupational therapy assessment involves a comprehensive evaluation of an individual’s ability to perform activities across all domains of daily life. These domains include work, education, activities of daily living (ADLs), instrumental activities of daily living (IADLs), social participation, play, leisure, rest and sleep, and health management.

Occupational therapists assess the client’s capacity to engage in these tasks consistently, to an acceptable standard, and within a reasonable timeframe. Observations are made not only of the individual’s performance but also of environmental factors that may support or contradict the client’s perceived functional capacity.

The assessment process is collaborative, often involving input from the individual, their family, caregivers, and other healthcare professionals. This collaboration helps form a holistic view of the person’s current supports, access to treatment, and the presence—or absence—of a supportive environment, all of which significantly influence functional capacity.

Findings from the occupational therapy assessment highlight areas of occupational dysfunction resulting from trauma. These may include disruptions to daily routines, difficulties engaging in meaningful occupations, and neurological or sensory impacts such as challenges with self-regulation, emotional expression, and sensory processing. The assessment also considers the influence of mental health conditions and potential substance use disorders on the individual’s ability to function effectively in daily life.

Quantifying Damages and Recommendations

Occupational Therapist play a critical role in quantifying damages by assessing the type, intensity and duration of both current and future support needs. These support needs may include commercially provided personal and domestic care particularly in cases where the individual demonstrates limited capacity to perform everyday tasks, even with assistance from a mental health support worker.

In some cases, assessment findings may indicate that the individual has regained partial functional capacity within a well-structured, safe and supportive environment. Here, the therapist evaluates existing supports to determine whether additional care is required. Future care recommendations may focus on enhancing skill development and participation, potentially involving a mental health case manager or support worker Where individuals have had limited or no access to appropriate care in the past, recommendations may include a staged approach. This allows time to assess whether the individual can respond to support and gradually increase their capacity and participation.

To support the development and maintenance of healthy routines, occupational therapists may recommend adaptive technologies.

These can include:

• Structured daily planning apps (with trial and annual subscriptions) to assist with task scheduling and routine building.
• Voice-activated assistants (e.g., Amazon Echo, Google Home) to provide reminders, task lists, and motivational prompts.
• Sleep hygiene tools, such as the Calm app, to support the establishment of a consistent and restorative sleep routine.

A medico-legal occupational therapy assessment provides a comprehensive overview of the survivor’s functional limitations and strengths. It offers practical, evidence-based recommendations to support the development of healthy routines, coping strategies, and compensatory techniques—ultimately enabling greater participation and quality of life.

References:

• [1] Final Report (2017) www.childabuseroyalcommission.gov.au
• [2] https://ottheory.com/therapy-model/framework-doing-being-becoming
• [3] The Impact of Childhood Trauma on Sensory Processing and Connected Motor Planning and Skills: A Scoping Review https://pmc.ncbi.nlm.nih.gov/articles/PMC11199431/
• [4] Sensory Modulation Dysfunction in Child Victims of Trauma: a Scoping Review https://pmc.ncbi.nlm.nih.gov/articles/PMC8586279/
• [5] The Impact of Childhood Trauma on Sensory Processing and Connected Motor Planning and Skills: A Scoping Review https://pmc.ncbi.nlm.nih.gov/articles/PMC11199431/