Online Therapy with Kids, Teens & Pre-teens: The Verdict
When COVID hit the world, and Australia, the shift to online has been quite overwhelming for the whole population including businesses, education and the health sector. Where previously we had used online sessions with clients in different states or in remote regions, our clinic had to quickly make the shift to conducting online sessions with most clients in a matter of weeks following lockdown laws. As an essential service, we continued operating both face to face as well as online to ensure we encourage people to stay home to reduce COVID spread whilst adhering to infection control policies in line with the Department of Health.
When it comes to conducting an online session with adults, this is usually not a big challenge, as they have the ability to communicate, listen and attend throughout the 50-minute session. Working with children online however has been somewhat of a challenge and learning curve particularly with the younger age range (4-9-year-old) given their difficulties in regulation and attention as well as need for movement and requirement for hands on play activities. In contrast, as practitioners, working online sessions with older primary school children, adolescents and young adults has been successful on the most part given that there had been a previous rapport established.
The following lists a summary of our experience and what we learned delivering online services with our clients based on age and presentation.
ONLINE SESSIONS WITH YOUNGER KIDS: PARENTS NEED TO BE INVOLVED
With the younger population, parents often needed to be involved due to several reasons including (but not limited to); experiencing technical issues, containing the siblings, the child going off the screen or losing attention/ becoming distracted with surroundings. Some kids embraced the online experience as they even seemed thrilled to show off their house, room, pets and favourite items! Although this would take away the focus on the session content at times, for them it meant allowing the psychologist to ‘enter their world’ which was very different than them coming in to see the psychologist at the clinic. Working with the parent given the circumstances and setting up a suitable space (e.g. limited toys, siblings cannot access) for kids to log onto their online session was ideal but not always possible. Similar to face to face therapy, sessions needed to be structured and interactive, but it was more of an essential requirement for online sessions for the child to remain engaged. Parents were also required to be available to provide the supplies for young kids (e.g. craft, building, dolls, etc.) during their online interaction.
THE VERDICT: With preparation from the therapist and in collaboration with the parent, online therapy was not entirely ‘impossible’. Kids were generally comfortable with using technology and may in fact prefer it nowadays. Although many clinicians and therapists have made claims that telehealth was ‘going really well for the clients’, we found that face to face therapy with younger kids is a much more interactive experience as it involves hand on tasks, spending time playing and doing activities that require the physical presence of each party. It allows better screening measures of a child-parent attachment and the child's overall development (i.e. their attention, regulation, social interaction) through behavioural and clinical observations, which is not entirely possible to gather online through a screen and online medium.
ONLINE SESSIONS WITH OLDER CHILDREN AND TEENS: CASE BY CASE
Sessions with new young people in general required parents to be present given that rapport was not yet established with the young person. This does make sense as most of their interactions online would generally be with familiar others that they have met and have established some sense of trust and rapport with. Inviting a complete stranger into your living space including your home and room, can be somewhat ‘odd’ and confronting especially for those with social and emotional difficulties!
With current and ongoing clients, however, online sessions differed depending on the young person’s presentation and/or personality. For example, talkative and bubbly personalities seemed comfortable in their own room, chatting away online and jumping from one topic to another whilst they sat around seemingly at ease in their surroundings, sharing information spontaneously and excitedly. In contrast, socially anxious young people seemed more emotionally flat and appeared somewhat uncomfortable. Given their heightened anxiety regarding their performance and social interactions, they did not appear to ‘dig the spotlight’ which is a challenge when delivering online therapy. Given that being in the spotlight is not something that socially anxious people aspire to, an online session with a complete focus on speaking and how you present may have somewhat increased their level of anxiety. On the other hand, some presented with their hair groomed and changed into a well-presented outfit before their online session, which may have helped in building their confidence during session!
Overall, both extroverted and introverted personalities responded well to items shared in screen share as well as online based joint activities. One important aspect of working with young people particularly with teens, is ensuring that there is evidence of their whereabouts, especially for those high-risk clients (e.g. risk of self-harm, conduct behaviours etc.). Sessions could therefore be started off at home with a catch up with both parent and teen or otherwise deciding with the teen and parent on a ‘known and safe place’ when logging onto their online session and having emergency contact details readily available in case they were at any risk of safety.
THE VERDICT: With older children and teens, there was a preference for rapport to have been established with the clinician in a face to face format. Without the established rapport, some were often hesitant to communicate online with someone unfamiliar but seemed generally okay if a parent was present with them, even just to start with. Teens and preteens who had adequate language and communicative skills, attention and regulation seemed to enjoy online sessions, if they were not socially anxious, unless attention was swayed away from them through activities via screen share. In some cases, rapport was even better established with some young people as they communicated comfortably from their own room where they may even feel more safe and secure in their own surroundings.
Nevertheless, despite its limitations, online therapy does allow the opportunity to continue with therapy as hesitant as we may be in regards to whether or not it may the most suitable medium. The main advice we would offer to manage online sessions is by creating more structure in general as we do in a face to face session, prepare screen share materials and resources, and in the case of young children; preparing with the parent prior to the session regarding the space, resources required and conducting shorter and more frequent sessions with the child requiring the therapy.
Written By: Azza Brown, Principal Clinical Psychologist and Clinic Director
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