Background According to Article 12 of the United Nations Convention on the Rights of the Child, therapists are duty-bound to include children in decisions that impact them. Although occupational therapists champion client-centred, collaborative practice, there remains a paucity of studies detailing children’s rights and experiences of decision-making in pediatric occupational therapy. Purpose This qualitative study described the decision-making experiences of children, parents and therapists in occupational therapy. Methods Semi-structured interviews were conducted with 17 participants (six children, five parents and six occupational therapists), and data analysed using thematic analysis. Findings Three themes emerged: 1) Goal-setting experiences; 2) Adults: child-rights gatekeepers or defenders? and 3) Decision-making in context. Findings suggest that decision-making is mostly adult directed, and children’s voices are subsumed by adult-led services, priorities, and agendas. Implications Children’s rights need to be embedded as an aspect of best practice in providing services that are child-centred in occupational therapy practices and education.