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Effective occupational therapy clinical reasoning requires knowledge of what limits a client, why the limitation developed and how to best help the client. This qualitative study applies the lens of systems thinking to the clinical reasoning of occupational therapists working in two different pediatric practice settings to better understand what information influences their clinical decision-making. Data comes from semi-structured interviews and concept maps created by subjects while discussing two clinical vignettes common in pediatric occupational therapy. This research will spur innovative thinking about best pedagogical practice in occupational therapy programs and is applicable to the preparation of clinicians in related disciplines such as medicine, physical therapy or nursing.