Interventions for Online Therapy with Children and Youth

In response to "flattening the curve” of the spread of COVID-19 (coronavirus), many therapists, social workers, counselors, and others in the mental health field are taking their practices online. They have had to hurdle legal and ethical considerations, onboard new HIPAA compliant software, learn to troubleshoot, all while managing their emotions, and their client's fears around the pandemic. It has not been easy. But treatment must go on. So, many who work with children and youth are wondering, how do I do therapy online with them?

According to Marketing Chart’s 2012 survey, they learned that 42% of teens are more comfortable sharing information and are even more open online than in person. American Well (Amwell) has reported in 2017 that because of the benefit of experiencing therapy inside the comfort of the home setting*, it normalizes mental health care, and is especially useful for the generations of people who are accustomed to interacting with others online. Even a study posted in Clinical Child and Family Psychology Review in 2018 with 3,113 children ages 6-18 learned that computerized and internet CBT intervention for both depression and anxiety are effective forms of treatment for youth.

In my practice, I have found using online therapy to be useful with children, youth, and families. They are often able to open up quicker, and process emotions faster as they’re in an environment they already equate with safety. Access to their home life also allows me to witness and intervene in parent-child interactions that are more representative of their normal behavior. I also noticed that navigating video conferencing is easy for my young clients, as they have grown up with streaming technology. Many of them even know the common tips on troubleshooting (like restarting the program or closing other internet heavy programs). I mention all of this, aiming to bring comfort to those who have never done online therapy and are wondering if it will be at all sufficient for their under 18-year-old clients. 

There have been a variety of interventions I use with families and youth online. From screen sharing activities to regular talk-therapy interventions, it's easy to come up with a whole host of things to do with your child and youth clients. One less common go-to for me is DND, but not everyone is a geek, and learning how to be a Dungeon Master is its own set of skills.

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Any mental health professionals needing more guidance then what is in this blog post can purchase this resource guide I created. It is 100-pages and includes more interventions, legal and ethical considerations, how to maintain engagement, safety, build rapport, and even how to prevent online therapy fatigue.

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Teletherapy Interventions to use With Children and Teens: A Resource Guide

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Version 2 of the A 100-page digital resource guide designed for mental health professionals who work with children and teens online. Inside are interventions that can be used, considerations for safety, and even tips on how to address teletherapy fatigue. Created by Guidance Teletherapy Clinical Director Ariel Landrum with the hopes of supporting her colleagues as they navigate the digital realm. (New Version has updated links and corrections on grammatical errors— Guide is sold “As Is”)

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Online Interventions

Below are a few you can use with children and youth**:

• Simon Says: Rules are simple. One person is designated as Simon, provides instructions to others, which they must obey. The other player/s lose if they follow a command that does not have the phrase "Simon Says" in the beginning. Both the therapist and the client take turns to be Simon. They can give directives like "Simon says stand up. Simon says, sit down. Stand up. Gotch-ya. “ Simon didn't say." Simon Says is a tremendous therapeutic game to integrate the shifts of high-low arousal during higher brain functioning processing (paying attention and decision making when excited). Process with your client, or family, feelings of frustration around losing, and the excitement around "telling a grown-up what to do." 

• Charades: A mimicry game where the intention is to guess the word or phrase that someone is acting out. The therapist can choose to take turns with the client or choose either themselves or the client as the person acting out or guessing. Categories can be animals, sports, videogames, things in the sky, or professions. A therapist can send topics to the family beforehand, so the client has time to come up with some ideas. Use this game to process communication styles, interpretations of how something was acted out, and the concept of shorthand communication (including the shorthand they may unknowingly use with friends and family).

  • If you’re needing help coming up with words, another clinical left a comment suggesting the using a word generator, and offered up GamerGal as a resource.

• I-Spy: Individuals take turns trying to guess which nearby object was selected in secret, through description queues given by the selecting player. The therapist and client can choose a theme for the round (like colors, soft or hard objects, shapes, etc.). The game starts with a selected theme. The person who is "it" will  spy something in that theme, saying, "I spy with my little eye (insert themed object)." The therapist must establish the rule that the object must be visible by the camera and that neither the therapist or the client can use themselves to block the object. This is a great game to improve language development as it reinforces vocabulary, and pro-social engagement, as the point is to help the other person guessing.

• Going on a Picnic: This game is perfect for communication building and sequential cognitive connection. Though it can be played with the therapist and the client, it has better therapeutic results with families. Using the ABC's as the framework, someone will begin the game with "I am going on a picnic, and I'm bringing (choose a food item that starts with an “A”, like apple, artichokes, avocados, or a silly thing, like an astronaut or an airplane). The next person repeats what the first person said, and then adds another item (that starts with a “B”). Repeat this until the entire alphabet has been used. If someone forgets an item, then the round starts over. You can even create their picnic story into an digital book, with My Storybook. Discuss ways for the family to remember details (teaching supportive communication). Process frustrations when something was forgotten, and the game must start over, or potential sibling rivalry regarding the speed of memorization and gameplay.

• Reading: Any book can be read out loud. The therapist can let the family know before the session, so that the client can choose a book to read. The therapist can also choose to read books they have. Remember to show the page and images to the camera. If the therapist has a library card, they can also reserve a digital book online, screen share with the client (if their HIPAA compliant software allows this), and read together. Pro Tip: practice reading the book before meeting with the client so you can do voices for different characters. I have an LA Public Library Card and use the online website Hoopla, which allows me to download 15 titles a month. They have a variety of books, even comic books, and Disney books. Great books to read and process that is available on Hoopla include:

  • Hey, That’s My Monster! By Amanda Noll and Howard McWilliam

  • Pete The Cat and the Missing Cupcakes by James and Kimberly Dean

  • Tiny T. Rex and the Very Dark Dark by Jonath Stutzman

  • Be Quiet! By Ryan T. Higgins

  • Olive the Sheep Can’t Sleep by Clementina Almedia and Camila Silva

  • Yes I Can!: A Story of Grit by Mari C. Schuh and Mike Bryne

  Additionally, if you’re not the best at reading out loud, or you find your space is too cramped to be able to read and show pictures regularly, you can go on YouTube and find pre-recorded readings of books. Her are some of my go-tos:

  • The Invisible String by Joanne Lew-Vriethoff

  • Something Very Sad Happened by Bonnie Zucker

  • How Full Is Your Bucket? by Tom Rath and Mary Reckmeyer

• Coloring: There are a variety of free coloring pages found online. Simply type "free coloring page" in Google. Choose some and send them to the family before the session so that they can download, print, and get the necessary coloring tools available. This is a good option for families that have crayons or other coloring media in the household. As an art therapist, I utilize coloring in various ways. Use this intervention to discuss with the client their choice of colors, decision-making around what to color when, and their judgments or self-critic of their coloring work.

• Worksheets: There are a variety of free worksheets found online. Simply type "free therapy worksheets for kids" in Google. Choose some and send them to the family before the session so they can download, print, and get the necessary materials to fill it out. This is a good option for families with crayons and writing utensils at home. These items can be assigned as homework to bring into the next session. Focus on processing with the client the prompts and responses on their worksheets.

• Videos: If your software allows for screen sharing, share a mindfulness YouTube video, or other appropriate psychoeducation videos, in session. To maintain control, I screen share and play the video instead of the client. I allow the client to send me a list of topics they want to learn more about, and I research age-appropriate videos to play during the session. Sometimes, depending on the sensitive information in a video, I will send it to a parent/guardian for approval. I will have the video cued up, with the ads already skipped and any unnecessary intros already jumped. I then mute the client so there is no feedback, and they hear the video through their speakers and watch it on the shared screen. If a client needs to ask a question or tell me something, they communicate a pause. We use a gesture we agreed upon for unmuting (I often teach them the ASL sign for “comment”). Additionally, they can message me inside the video software if they don't want to stop the video. At the end of each video, we process the client's reactions to the content. Videos I have used in a session include: 

  • Coronavirus disease (COVID-19) from CDC (this is new to my repertoire due to the current pandemic)

  • Kid’s Questions About COVID-19 Part 1 and Kid’s Questions About COVID-19 Part 2 from Alberta Health Services

  • Be The Pond from Cosmic Kids Yoga

  • Depression Explained from Professor Puppet

  • What Causes Anxiety and Depression - Inside Out from Mind Set

  • Preventing Childhood Anxiety and Depression from GoStrengths!

  • A Student with Mental Illness from Chara Bui

  • We Described Our Depression To An Illustrator from BuzzFeedVideo (I do something similar to this with youth during sessions)

  • Do All Autistic People Think The Same from Jubilee

  • 6 Middle Schoolers Versus One Secret 5th Grader from Jubilee

  • Do All Teen Moms Think The Same from Jubilee

  • Do All Teen Dads Think The Same from Jubilee

  • Do All Suicide Survivors Think The Same from Jubilee (this one I often show families who do not understand their youth’s suicidal ideation or attempt to minimize it by believing it is only attention-seeking behavior)

• Show and Tell: Show and tell is the practice of showing something significant to someone and discussing it. Children love to show you their world. With online therapy, you can see their home, particularly their room (if you were not doing home-based treatment). If the child's computer isn't directly plugged into the modem, give the child a tour of their room, explaining the different items and their importance. Have the child show off an essential comfort/self-soothing item (like a teddy bear or blanket) and explain why it is comforting. Have them take you to various rooms in the house that are of importance. Have them share culturally significant items or rooms, like family heirlooms, religious items, or alters, and discuss what they mean to the family and the child. Some children even show me urns that contain loved ones and share stories about them (this is great for grief-processing work). This entire exercise is fantastic for rapport building.

• Board Games At Home: If the youth have board games like Sorry or Candyland, you can have them set up the game and play the pieces for you. It's an excellent opportunity to discuss "being a helper" and diversity. Process what it is like to assist someone unable to physically touch or interact with the objects. This opens the conversation around experience with individuals with disabilities and social distancing to help prevent the spread of COVID-19 (coronavirus). This also allows the therapist to challenge the temptation to cheat. A therapist can use their gameboards and have the client describe which pieces to move. I choose not to do this only because youth can get distracted when they aren’t engaging with the pieces.

• Feeling Faces: Discuss feelings using feelings flashcards that have faces on them (I created some with emojis, which the youth love). Show a face on the screen and have the youth label the feeling. Then try to have the youth make the same face. This creates emotional recognition and mirroring emotional states, which increases empathy. Try to include somewhat goofy faces that are hard to replicate or animal faces (like a pig), making it more challenging and fun for children. You can even send the flashcards to the family to print out, so the youth can choose feeling faces for you to identify and imitate. There are also free printable flashcards with question prompts around emoji feeling faces that can be used.

• Whiteboard or Jamboard: In in-person therapy, therapists often use a whiteboard or a dry-erase board for psychoeducation or interventions such as tandem drawing. I use GSuite, which allows me to have an interactive whiteboard through a program called Jamboard. Some HIPAA-compliant videoconferencing software includes using a whiteboard, such as Zoom Healthcare and TheraPlatform. I create a Jamboard session, share the private link with the client, and we work on the board together, or they work on it alone. For art therapy, I will use the bridge assessment/intervention and motivational interviewing to help address the challenges the youth faces. Sometimes I will draw a line down the middle of the board or create circles around the board to represent boundaries that the youth and I have to honor. I also use a cognitive processing exercise with a child where we take turns drawing a line until we have created an entire picture. Lastly, with Jamboard specifically, I can import a coloring image page and color it together using the pen tool.

• Puppets: One advantage to not being in front of the client, and instead online, is that puppetry is easier! Young children especially love seeing puppets on the screen. Puppets can add humor and levity to a session. Inform the parent/guardian before the session that you’ll be puppeteering, so they can be in the room to help the young client, depending on their age. If they aren’t participating in the session, they can sit in the room with headphones and stream something. For slightly older clients (6 to 7), the parent doesn’t have to be in the room. Have a story prepared to tell the client, tell jokes, or discuss feelings and where they are felt in the body. Keeping the experience non-directive can also encourage imaginative thinking, autonomy, and free expression.

• Podcasts: If your software allows for screen sharing, share age-appropriate topics from Podcasts. Share a clip or the entire Podcast, depending on the length of the session. Depending on the sensitive information in a Podcast, I’ll send it to a parent/guardian for approval. I’ll have the clip cued up, with the ads already skipped and any unnecessary intros already jumped. I then mute the client from my end so there is no feedback, and they hear the Podcast through their speakers. If they need me to pause or want to ask a question, they use a gesture we agreed upon for unmuting. They can also message me inside the video software if they don’t want to pause. In the end, we process the client's reactions to the content. The Podcasts can be useful resources for the clients to utilize as coping skills. Often I assign a Podcast to listen to as homework, with a worksheet to complete and process their reactions in the next session. These are good for family therapy as the whole family can process their responses to the information and discuss it in family therapy. Podcasts I have used in a session include:

  • Play Time: A Play Therapy Podcast with Andrew Barnett of Barnett Child Therapy

  • Play Therapy Community Podcast with Lisa Dion of Play Therapy Community

  • Kid Therapist Podcast with Allison McQuaid

  • The Better Mental Health for Kids and Parents Podcast with Dr. Fasano

  • Short and Curly with Dr. Matt Beard, Carl Smith, and Molly Daniels

  • Unspookable with Soundsington Media

• Online Gaming: Plenty of ways to play games online with children. Avoid any games that involve substantial multiplayer or online community experience that need to be downloaded or require a screen name. If you must create a log-in, ensure it is with your HIPAA-compliant email and something nondescript like "person85." Play Uno, checkers, or chess, or connect four with Skill Games Board. Play card games like Go Fish or Match with PlayingCards.io. You can even get a free Minecraft Serve through Aternos. Minecraft is a great game to discuss home life. For art therapists, it is a digital way to do the House portion of the House-Tree-Person Assessment. Even nonart therapists can discuss home life without doing it as an assessment. Work with the youth to build a home. It isn't difficult for someone who hasn't played before to learn. The goal is to have the child do most of the work themselves. Talk about what makes a home safe. Have them focus on "comfort zones," "safety measures," and "areas to avoid without supervision." These will take parent consent, consenting to opt-in to use online gameplay for therapeutic means, and discussing the benefits and risks.

Housing Keeping

Some of these interventions involve preparation. Some include sharing information with the family beforehand or additional parental consent. Be mindful of this. Additionally, when considering online therapy, I establish a few housekeeping rules and interventions right away. The idea is to maintain therapeutic control, and it can feel like you have a minimal amount when you're not physically with your client.

So here are a few housekeeping rules and interventions that can help you keep the session therapeutic:

• Every session confirms the client’s location (this is part of teletherapy ethics). Eventually, you will become used to the background, but if things change, this needs to be documented in your progress note.

• Every progress note, a document that you “assessed and confirmed client is still appropriate for teletherapy” (unless they aren’t, and then you note that and what steps you took to refer them out or kept them safe).

• In order to make eye contact with the client, do not stare into the camera. It won’t look like eye contact. You’ll lose important facial and body cues. Instead, take your screen out of full view. Minimize it so it takes up to 2/3rds of the screen. Center it directly under your camera. Look at your monitor, not the camera, and you’ll look directly into the client’s eyes. Teach them to do the same.

• Discuss, or create, a “Privacy Agreement” for family members (or members living in the home who are privy to services) to adhere to regarding respecting the time as therapy time, not barging in or interrupting a session, and not listening in by the door, etc., when session is taking place.

• For teens, who are especially concerned about privacy, discuss downloading a white-noise app and having that play by their door while they are in session. Get prior permission from parents/guardians if they monitor app downloads on their youth’s phone.

• Discuss using headphones for privacy.

• If possible, have parents turn off notifications on the youth is device to prevent the temptation of going online.

• Discuss respecting the time as therapy time. Encourage not logging into social media or responding to notifications. Have a discussion on respect, and inform them that you value their time as well and will also not be logging into social media or responding to notifications.

• Discuss how unnecessary activity online will cause disruptions in the streaming feed. It will result in grainy video images or crashes. Youth understand this very well and will often comply because of this.

• For younger youth, encourage parents/guardians to provide them with fidget objects or comfort objects to grab onto during session. Talk about using words as emotional hugs and have them replicate it with physical hugs towards their comfort object. Talk about mindfulness and awareness of the body and utilizing the fidget object to respond to body sensations of annoyance or boredom.

• Have specific sessions designed for the youth to screen share their online life. When youth know this will occur during a session or a website at the end of each session, they are not tempted to go online during therapy. Have them screen share and show you their social media pages (talk about cyberbullying, reporting harassment, blocking people, how it feels to get a "like," who their close friends are, their favorite memes, who or what they follow, etc.). Gamer clients can give a tutorial of the game they play (ask about the friends they have made on gaming, what skills they have or how they contribute to the gaming party, ask about problem-solving during the game, team building, and inner game communication, etc.). If they have online school or online assignments, have them give you a tutorial on how school works (ask how they turn in assignments, get help from other students or teachers, take notes, create study groups, etc.). Online life sharing builds rapport and provides necessary insight into stress, struggles, and support the youth has.

• When possible, have parents join the first few sessions. This will create stability as they help the youth manage not using the computer for anything but online therapy during the session. It can help lead to parent-child communication and discipline discussions.

• I also do prep work with my youth, prone to disassociation. I teach them grounding techniques, including describing objects in their room and describing objects they see in my room. I have even taught them to type responses to feel the keyboard and hear the keys clacking.

• Teens can be prone to “posing” or looking at themselves in their reflection. Do not be afraid to draw attention to this behavior and attempt to teach them not to look at themselves. Pro tip: it can be hard for you to resist looking at yourself, so use a sticky note to block your minimized face (for anyone new to teletherapy, it can be subconsciously distracting).

Legal and Ethical Considerations

Before starting treatment, discuss the risk and benefits of online therapy with the client. Ensure they sign an informed consent that discusses the risks, including cyber security. Discuss ways to maintain confidentiality, including having sessions in a private room in the home, using headphones, and not sharing computer passwords. Also, discuss with parents/guardians the safety measures they will take to ensure the treatment is confidential, including keeping siblings not in treatment occupied, planning sessions when visitors are not coming over, and occupying pets.

It is important that your informed consent also reflect all the possible ways you will be interacting with the child, youth, or family online. It must describe the risks and benefits of supplemental digital engagement (such as online games or emailing material). When discussing the risks, highlight how even if a link is sent privately to the client, though unlikely, there is always the risk of cyber-hacking. Also, discuss the risk of receiving documents via email that may seem clinical or therapeutic (such as CBT worksheets) and that although you may have a HIPAA-compliant email, the communication isn't secure if your patient does not.  For this reason alone, you might want to provide resources for options to choose from when it comes to HIPAA-compliant email providers to make sure the emails are encrypted. You can also remind them that they can choose to communicate via email with the awareness that it isn’t encrypted, and this can still be considered working within HIPAA guidelines. Lastly, remind them to be mindful of who has access to their email.

Also, ensure that you provide parents/guardians with a tutorial on using the videoconferencing software and keeping it private. If you’re using Zoom, Knoji’s Zoom Safety Guide offers several helpful and informative safety tips on navigating the platform. You’ll be able to learn some great tips and tricks, ranging from enabling waiting room features to removing unwanted participants in a call so that you can focus on staying connected with your clients without worrying about unwarranted “zoombombers.”

For parents who have reservations, you can share this video. It’s about speech therapy, but it’s from a parent’s perspective: What do parents think about teletherapy?

Go-To’s

Transitioning therapy online with youth, family, and children may seem daunting. Fear not. You are probably using in-person therapy for many of these interventions mentioned. We rarely have interventions where we need to "touch" a client. Consider your common intervention go-to's, add a screen, and visualize the barriers you must overcome to make that intervention possible. A whole host of common interventions can still be used in online therapy. Some include mindfulness meditation, journaling, empty chair technique, or therapeutic role play. With some solution-focused thinking, you'll see it wasn't as difficult as you made it out to be.

BONUS ACTIVITY: With the abundance of toilet paper everyone now has in their homes, here are 15 crafts to create with toilet paper rolls! Choose one with materials you and your client have on hand and create something together. Good project to do with parents/guardians and children to learn fine motor skills and follow directions.

What are the interventions you use for your online with children? Share in the comments below!

*Additional Awareness: This may not be accurate for individuals who have experienced abuse or trauma in their homes or have unsafe home environments.

** Additional Awareness: Please note that I am assuming before you use any of these interventions that you’ve already downloaded HIPAA-compliant software, have clients sign consents for online therapy, and discussed opt-ins regarding communication via email.

Anyone seeking advice on where to get started transitioning your practice online in response to COVID-19 (coronavirus), I created a blog post you can read.

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