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A Collaborative Approach To Pediatric Depression, Anxiety

miri compressedWe’re following up with pediatric occupational therapist Miriam Manela, who specializes in behavioral issues, whom we interviewed earlier in the week.

Tell us more about how you collaborate with mental health professionals.

Sure, I’ll give you an example. Recently I worked with a social worker in private practice. We worked together with a client I’ll call Jake. Jake is sixteen and in a special ed school. He’s challenged by learning disabilities and social delays.

He was very depressed and suicidal, making threats of killing himself. He gets very angry and either shuts down, which presents as not talking, or moaning and complaining repeatedly. He also has anxiety.

The social worker has been working with Jake on finding a solution for his anxiety, especially his breathing. Jake loves karate and so the therapist used this to help Jake understand that managing anxiety must be practiced like you practice karate. He practiced anxiety-reducing breathing techniques with Jake.

I worked with Jake on strengthening his core so that he was able to breath effectively. In his case, we used balloons and manual facilitation as a means of gathering all his breathing muscles to work together to get deep and robust breaths.  I also coached his mother. When he shut down I taught her to take the following steps, based on Dr. Ross Green’s theory.

I knew Jake would benefit from being more aware and having insight into himself. I also wanted him to be able to express what was going on inside him or at least, hear someone else express it and really understand what they were saying.

I asked Jake’s mom to speak to Jake at a neutral time, not while he was shutting down. These are the steps I had her take, speaking in a calm manner:

1. Identify what occurred. Saying something like: Hey, yesterday when you were at Miriam’s sensory gym you stopped talking when you didn’t get to do what you wanted to do. What’s up with that, Jake?

If he answers and tells you what happened, why he shut down, great! Just validate what he says by saying “so the reason you stopped talking is__________, did I get that right?

Don’t tell him how you’d like to see him improve in the future, or express how you dislike what occurred. Leave it be. He may have more than one reason, repeat and validate each one

If he isn’t able to answer, which at first will be far more likely, that’s okay. Just ask him if it’s okay for you to describe what you think was going on. In other words, ask his permission. Say: Is it okay if I share with you what I think is going on?

2. Next step, explain your concern from the perspective of the adult such as: I’m concerned because you have made so much progress in therapy and I know there are more areas you want to shift in your life and don’t want you to get discouraged from continuing. Or, I’m concerned that you have a hard time shifting from one mind-set to another.

Then, ask him: Can you understand what I’m concerned about?

Allow him to answer and then end the conversation.

Each time Jake and his mother has this conversation, the following times he became overwhelmed and about to go into shut-down mode, it became less and less intense for him. The frequency, duration, and intensity of the shut-down has been decreasing. By helping him become aware of what is going on, and helping him remember what worked for him in the past with me during his occupational therapy sessions, Jake’s mother is able to help him become more self-aware in a healthy manner.

3. I left step 3, problem-solving, to the mental health professional. In this step, both the mother and son compromise or agree to a way to make it work.

I think people think of occupational therapy as being very physical. Yet, what you are describing is a behavioral intervention.

It’s good to keep in mind that at least a third of OT training is in psychology

The beauty of working with our mental health while having the amazing equipment that my sensory gym provides and the skill base on how to work with people physically, is that everything can be combined in such a way that the child doesn’t necessarily realize they are working on their home life and social issues.

So, most if not all sessions include aspects of both the physical parts of being an OT and the mental health interventions as well.

About Miriam Manela, OTR/L

 Miriam Manela’s occupational therapy practice, Thrive!, is housed in a unique sensory gym, ‎and offers a safe space where children have the freedom to explore and grow. She uses a creative, integrated treatment approach and loves working closely with parents to help them achieve a healthy, responsive, and mutually satisfying parent-child relationship.

Miriam’s new book, The Parent-Child Dance, written with C.R. from the Therapy Soup blog, is due out this fall. We’ll tell you more about it in the coming months. Be sure to visit Miriam at to learn more about how pediatric occupational therapy may help with your child’s behavioral issues.

A Collaborative Approach To Pediatric Depression, Anxiety

Richard Zwolinski, LMHC, CASAC & C.R. Zwolinski

Richard Zwolinski, LMHC, CASAC is the author of Therapy Revolution: Find Help, Get Better, and Move On Without Wasting Time or Money and is licensed in addiction and psychotherapy with over 25 years experience as well as a consultant to organizations and companies in the fields of mental health and addiction. He is the executive director of an outpatient behavioral health program. Learn more about Richard here.

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APA Reference
& C.R. Zwolinski, R. (2019). A Collaborative Approach To Pediatric Depression, Anxiety. Psych Central. Retrieved on August 6, 2020, from


Last updated: 30 Mar 2019
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