The COVID-19 pandemic led to a rapid and marked change in how so many of us provide clinical care, pivoting from majority in-person services to telehealth in a matter of weeks. In so many ways, telehealth was a gift, allowing us to provide care when in-person was impossible. At the same time, questions arose around acceptability and effectiveness, as well as common concerns related to engagement and avoidance with a virtual twist. I think many of us were surprised by how well clinical practice translated to online platforms, bolstered by a growing and promising body of research on CBT for youth anxiety delivered via telehealth, and the excitement of leveraging technology to engage in exposure work across settings and situations. Now that telehealth and in-person services are available, what are important factors for clinicians, youth, and families to consider?

Access to care. Does telehealth enable this youth to access evidence-based care?

Many youth live in areas where the need far outweighs the number of providers trained in CBT for anxiety. For youth who do live geographically close to trained providers, transportation costs, travel-time, and scheduling constraints continue to be significant barriers to care. Telehealth offers a compelling solution, allowing youth to access specialty care from their home or school and eliminating travel time, with many of us also noticing a decrease in late cancellations and no-show appointments.

Youth age and development. Is telehealth developmentally appropriate for this youth? What role do caregivers play?

The youth’s capacity to focus and engage in a video session is a key consideration. Many teens are quite comfortable connecting and communicating via technology and might have an easier time with telehealth than younger children. Involving parents more in session, parent-directed interventions (e.g., the SPACE program developed by Dr. Eli Lebowitz et al) and dyadic interventions (e.g., PCIT-CALM developed by Dr. Jon Comer et al) offer possible solutions for providing appropriate care for younger children via telehealth.

Presenting Anxiety Concern. Is the youth able to target their treatment goals via telehealth? What are benefits or drawbacks when tailoring exposures?

For many youth, the vast majority of situations that cause elevated anxiety occur at home or school. Having telehealth sessions in these settings can facilitate in-session exposures that directly target the feared situations, and aid generalization of therapeutic gains outside of session. For example, a youth with contamination OCD symptoms with avoidance or compulsive behaviors in their bedroom can complete in-session exposures in that space, rather than trying to approximate exposures in the clinic setting. The ability to access a child’s home environment also provides additional information about possible parental accommodations (e.g., ways parents inadvertently become part of the anxiety cycle by helping their child to avoid or escape from situations that elicit anxiety) and may simplify caregivers joining session to support treatment. On the other hand, it might be trickier for a youth with social anxiety to complete social exposures when they are participating via telehealth at home compared to in-person. Here an extra degree of creativity (leveraging social media, exposures in other public settings, virtual reality) or considering group CBT treatment may be needed. In many cases, facility of exposure work may be similar in-person and virtually, and other factors take priority.

Engagement. What are differences in therapy-interfering behaviors for telehealth compared to in-person? How can these behaviors be addressed?

Exposure is the key ingredient in CBT for anxiety. At the same time, it’s quite common for youth to fall back on avoidance, safety, and escape behaviors to some degree when facing fears. Whether sessions are virtual or in-person, a treatment plan that aims to reduce these anxiety-maintaining behaviors is essential, and these behaviors might show up differently with telehealth. Some common examples include looking away from the screen/angling the camera away, using technology and other items for distraction, writing in the chat instead of talking, turning off the video, or even having “technical difficulties”. Psychoeducation about the role of avoidance and safety behaviors, setting clear expectations and guidelines, caregiver involvement, use of motivational interviewing, making exposures gradual, and using rewards and behavior support plans are all possible interventions to increase engagement. When therapy-interfering behaviors remain, reviewing the treatment plan and appropriateness of telehealth services is likely needed. Some youth may also have co-occurring concerns, like attention difficulties, hyperactivity/impulsivity, or developmental concerns that make telehealth more challenging. These warrant consideration when deciding if telehealth is appropriate.

 Risk Management. What is the level of risk? Given level of risk, are other services more appropriate?

A discussion of risk management via telehealth is beyond the scope of this post. At the same time, understanding risk factors like suicidal ideation and behaviors, self-harm, depression, and substance use is important when determining whether telehealth services provide adequate support. When risk is a concern, other services instead of or in addition to telehealth must be considered, such as crisis resources, options for in-person appointments, and/or higher levels of care.

Patient and Provider Preference. All else being equal, what are the provider and patient preferences? Providers and patients may have their own preferences. Indeed, the future might be hybrid, with increased flexibility about using both telehealth and in-person appointments to better meet patient (and provider) needs. Telehealth acts as another clinical tool to increase access to care, facilitate generalization of gains through targeted exposure work, and meet clinician and family needs and preferences.

The American Psychological Association’s Telehealth guidelines for the practice of telepsychology can be found here: https://www.apa.org/practice/guidelines/telepsychology.

This post is presented in collaboration with ADAA's OCD and Related Disorders SIG. Learn more about the SIG.