Emotional distress can affect more than how someone feels. It can make it harder to begin an activity, tolerate uncertainty, transition between tasks, participate in social situations, or manage everyday responsibilities.

For some children and families, these difficulties can contribute to repeated struggles around school attendance, homework, bedtime, trying unfamiliar activities, or separating from caregivers. The situations vary, and similar outward behaviors can have different underlying causes.

Occupational therapy can examine how emotional and regulation challenges affect everyday participation. By understanding the demands of an activity and the circumstances surrounding it, OT may help identify supports that make participation more manageable.

Even when anxiety or another mental health condition requires specialized psychotherapeutic treatment, occupational therapy may complement care provided by qualified mental health professionals.

Understanding Regulation and Participation

Regulation involves the processes that help a person respond to internal states and environmental demands. These processes can influence attention, behavior, engagement, and the ability to recover when a situation becomes difficult.

Co-regulation refers to the ways supportive relationships and interactions can help a person manage distress and develop regulation capacities. In children, caregiver responses and the surrounding environment may be relevant to how difficult situations unfold.

Avoidance is more complex than simply refusing to participate. A person may avoid an activity because it feels overwhelming, unpredictable, physically uncomfortable, socially demanding, or difficult to manage. Understanding the reason for avoidance is important when determining an appropriate response.

What Does the Research Explore?

Ben-Sasson, A., & Zisserman, A. (2025). Sensory family accommodation for autistic and sensory overresponsive children: The mediating role of parenting distress tolerance. The American Journal of Occupational Therapy, 79(3), 7903205110. https://doi.org/10.5014/ajot.2025.050790

What the research explores: This study examines sensory-related family accommodation among families of autistic children and children with sensory overresponsivity, including the role of parenting distress tolerance. It considers how caregiver experiences may relate to family responses to children's sensory needs. Relevance to our approach: When a child experiences distress or avoids a situation, supporting the family may involve understanding both the child's experience and the demands on caregivers. We help families consider practical responses that respect individual needs while supporting participation in meaningful activities.

Cahill, S. M., & Beisbier, S. (2020). Occupational therapy practice guidelines for children and youth ages 5–21 years. The American Journal of Occupational Therapy, 74(2), 7402397010. https://doi.org/10.5014/ajot.2020.744001

What the research explores: These occupational therapy practice guidelines summarize evidence and recommendations for OT services for children and youth ages 5–21. They provide a professional framework for considering intervention approaches in relation to children's needs and participation. Relevance to our approach: We aim to connect therapeutic strategies with the activities and situations children encounter in daily life. Our work considers how emotional, behavioral, and other individual needs may affect participation and what supports can make everyday activities more manageable.

Etkin, R. G., Winograd, S. M., Calhoun, A. J., Silverman, W. K., Lebowitz, E. R., & Shapiro, E. D. (2024). Pilot study of a parent-based intervention for functional somatic symptoms in children. Journal of Pediatric Psychology, 49, 900–910. https://doi.org/10.1093/jpepsy/jsae092

What the research explores: This pilot study examines a parent-based intervention for children experiencing functional somatic symptoms. It contributes preliminary information about a caregiver-focused approach to addressing children's symptoms and related family responses. Relevance to our approach: Parent-focused approaches can offer useful perspectives on how caregiver responses may affect the way families navigate difficult situations. We draw on relevant research to inform our clinical reasoning while distinguishing between interventions studied in the literature and the specific services Center Ring Therapy provides.

Grajo, L. C., Candler, C., & Sarafian, A. (2020). Interventions within the scope of occupational therapy to improve children’s academic participation: A systematic review. The American Journal of Occupational Therapy, 74(2), 7402180030.

What the research explores: This systematic review examines occupational therapy interventions intended to improve children's academic participation. It provides evidence relevant to the role of OT in helping children engage in school-related activities including addressing school-avoidance. Relevance to our approach: School participation and attendance can be affected by a range of individual and contextual factors. We consider the specific barriers a child encounters and identify supports that may help make participation more accessible.

Kingsley, K., Sagester, G., & Weaver, L. L. (2020). Interventions supporting mental health and positive behavior in children ages birth–5 years: A systematic review. The American Journal of Occupational Therapy, 74(2), 7402180050p1–7402180050p29. https://doi.org/10.5014/ajot.2020.039768

What the research explores: This systematic review examines interventions intended to support mental health and positive behavior in children from birth to age five. It synthesizes evidence relevant to intervention approaches for young children. Relevance to our approach: Supporting young children's participation may involve helping the adults around them respond consistently and adapt everyday situations to meet their needs. We consider each child's developmental profile and the family's priorities when identifying practical supports.

Lebowitz, E. R., & Majdick, J. M. (2020). SPACE, parent-based treatment for childhood and adolescent anxiety: Clinical case illustration. Journal of Cognitive Psychotherapy, 34(2), 101–115.

What the research explores: This clinical case illustration describes SPACE, a parent-based treatment for childhood and adolescent anxiety. It provides an example of how a parent-focused approach may be applied in clinical practice. Relevance to our approach: Center Ring Therapy practitioners have completed SPACE training with Dr. Lebowitz. We are interested in ways parents can respond to anxiety-related challenges while supporting children's growing participation and independence. SPACE-informed concepts inform aspects of our parent coaching.

Shimshoni, Y., & Lebowitz, E. R. (2020). Childhood avoidant/restrictive food intake disorder: Review of treatments and a novel parent-based approach. Journal of Cognitive Psychotherapy: An International Quarterly, 34(3), 187–204.

What the research explores: This review discusses treatments for avoidant/restrictive food intake disorder (ARFID) in children and presents a novel parent-based approach. It considers caregiver involvement in the context of children's eating-related difficulties. Relevance to our approach: This literature offers a perspective on the role of caregivers when a child's challenges affect everyday family life. When considering parent-focused strategies, we attend to the child's individual needs, the family's priorities, and the specific participation goals being addressed.

Simpson, K., Adams, D., Malone, S., Tucker, M., Rapee, R. M., & Rodgers, J. (2023). A parent-mediated anxiety intervention specifically tailored for autistic preschoolers: A pilot study. The American Journal of Occupational Therapy, 77(2), 7702185100.

What the research explores: This pilot study examines a parent-mediated anxiety intervention adapted for autistic preschool-aged children. As a pilot study, it offers preliminary information about the intervention and the feasibility of studying this approach in this population. Relevance to our approach: The study is relevant to our interest in helping caregivers respond to anxiety-related challenges in everyday situations. It also highlights the importance of considering how parent-focused support is presented and adapted to families' needs.

How This Research Informs Our Approach

At Center Ring Therapy, we look at what happens before, during, and after a difficult activity. We consider the individual's regulation needs, the demands of the situation, the supports available, and the patterns that may be making participation harder.

Parent coaching by an occupational therapist may help caregivers understand how to support co-regulation, and make thoughtful adjustments to everyday situations.

The appropriate approach depends on the underlying difficulty. Some children need environmental or sensory supports; others may need help developing coping strategies, practicing participation, or accessing specialized mental health treatment. These needs can overlap.

Our goal is to help families identify useful, individualized next steps without assuming that all distress has the same cause or requires the same response.

Related Resources

• Explore our Parent Coaching services.

• Learn about Parent Coaching and Caregiver Involvement.

• Return to The Research Behind Our Approach.

Understanding the Evidence

The research cited on this page includes different types of evidence, including systematic reviews, practice guidelines, intervention studies, and observational research. Each contributes a different kind of information.

Some studies directly evaluate occupational therapy interventions, while others examine related approaches or investigate factors that influence everyday participation. Findings from related disciplines can inform clinical reasoning, but they should not automatically be interpreted as evidence of the effectiveness of a particular occupational therapy intervention.

We aim to describe research in the context of the populations studied, the outcomes measured, and the limitations identified by the researchers. Individual care decisions should be based on each person's needs, goals, and circumstances.

This page was last reviewed by Hannah Swirnow, OTR/L, 2026.