Teletherapy for Kids: How to Work with Young Children during Virtual Behavioral Health Sessions

April 28, 2020


Working with children in a behavioral health setting can be challenging. Care providers may have difficulty keeping young children focused, communicative and engaged in the session even when they are in the same room together. Telehealth sessions with children make this task even harder, reducing the provider’s control over the situation as well as the immediacy of their presence.

We’ve previously shared some tips and best practices for engaging behavioral health consumers via telecommunication, and many of these suggestions can also apply to children. To recap, consumers should be coached through any aversions they may have to virtual care, encouraged to participate with motivational interviewing and rapport-building, and engaged with visuals and activities whenever possible. However, high-quality engagement throughout the session is especially critical with children, as they could easily lose interest when the provider is just a face on a screen or a voice on the phone.

Fortunately, it’s possible to conduct successful virtual sessions even with young children, and a growing body of research shows that telehealth therapies and behavioral interventions for children can be just as effective as in-person treatment. Care providers need only alter their engagement strategy slightly to keep young children interested and interacting in the session.

Dr. Ashleigh Woods, one of our psychologists here at Cummins Behavioral Health, recently held a training seminar to educate our staff on the best ways to work with children over phone or video chat. Her advice can be broken down into two categories: interventions for overcoming technical issues and limitations, and strategies for keeping children engaged during virtual sessions.

Making the Best of Technical Limitations


Ashleigh Woods, Psy.D., HSPP, Staff Psychologist at Cummins Behavioral Health

Depending on the age and disposition of the child, behavioral health sessions with children can be much more “lively” than those with teens or adults. Young children often like to move around, explore their environment and play with objects in the room, especially if elements of play therapy are being utilized in the session. Although these behaviors aren’t usually problematic during in-person sessions, they can cause some disruption when the provider can only see the child through the camera on their device.

Providers can take the following steps to compensate for these technical limitations:

1. Find the best camera position

If you are communicating via video chat (which is recommended over voice-only calls), you should work with the child at the start of the session to determine the best location for your camera. Ideally, you should be able to see as much of the area where the child may be interacting or playing as possible.

“I’ve found in my own work with kids that having the device on the floor tends to work out well for me, because that way I can see more of the space and what’s happening in it,” Dr. Woods says. However, you should also be prepared for this position to change as the child moves to different parts of the room or moves the device, which leads to our next point.

2. Anticipate and be patient about technical difficulties

Providers can save themselves some angst by accepting that no virtual session with a child will go completely smoothly. “As the clinician, we might feel that every minute of the video chat needs to be productive and goal-oriented, but I think that we need to have patience and know that the child is going to wander out of the frame. That’s just a normal part of working in this kind of virtual space with kids,” Dr. Woods says.

Instead of becoming flustered when this happens, respond with patience. If the child leaves the frame, simply let them know that you can’t see them and ask them to come back. Continue speaking to let the child know you’re still present, and calmly encourage them to move your camera or return to view. If you are direct yet reasonable about what must be done, most children will accommodate your needs so that the session can continue.

3. Ask the child to show and explain what they’re doing

Even when you’ve taken the above precautions, there will likely be times during the session when you cannot fully see what the child is doing. Instead of nitpicking the placement of the camera, it is sometimes easier to have the child bring items to you or verbally explain what they are doing off-frame.

“Any opportunity you have to ask the child to ‘tell me about,’ ‘show me,’ any of those kinds of things, you may have to take,” Dr. Woods explains. “You might need the child to be a little bit more aware of the position of the camera and that they might have to hold something up to show you, and they also might have to be more verbally engaged in describing what they’re doing or describing the item they’re holding.”

Improving Engagement in Virtual Sessions


In addition to overcoming technological limitations, providers must also do their best to keep children engaged throughout virtual sessions. Because the provider and child are no longer in the same room, it may be more difficult to build rapport and hold the child’s attention. Providers will need to change some of the ways they interact with children over video or phone in order to keep them interested and participating during the session.

Providers can use the following strategies to improve telehealth engagement when working with children:

1. For first sessions, try a “scavenger hunt” activity to build rapport

It’s important to establish a sense of trust and rapport in your first session with a consumer (especially with children), but this can be slightly harder to do when meeting virtually. If your first meeting with a child is conducted virtually, consider starting with a “scavenger hunt” activity in which you ask the child to find their favorite toys and tell you something about them.

“This intervention can apply for therapy, and it can also be modified for skills training,” Dr. Woods explains. “It’s a nice rapport-building, ‘getting-to-know-you’ activity. Most kids are going to be pretty excited to show off their space and the things they have at home.”

2. Use more verbal communication and instruction than normal

During in-person sessions with children, a significant amount of interaction may be nonverbal. For example, the provider might engage in an activity with the child or read their body language to assess what they’re thinking and feeling. Since this is often not possible during virtual sessions, you may need to rely on verbal communication more often than you normally would. Ask the child how they’re feeling when you can’t determine their mood, and instruct them to show you how they perform certain activities when you can’t do the activities with them.

“In the virtual space, we don’t have the luxury of being in the room with the child to see how the play is going to unfold, so there has to be a little bit more verbal conversation about it,” Dr. Woods says. “This can really encourage the child to get into the play and show the therapist how to play with the item. And as they show the therapist how they play with the item, the therapist can do all of the things they would normally do in play therapy, such as providing empathic reflections, wondering about thoughts and feelings, and seeing what conceptual themes emerge.”

3. Exaggerate your nonverbal communication and cues

Of course, nonverbal communication still has its place during virtual sessions. Facial expressions can be excellent tools for encouraging children or conveying your emotions to them, and inflection can be utilized to draw their attention to certain words. However, you should exaggerate your nonverbal cues when communicating virtually so they are easier for children to pick up on.

“It’s harder to convey emotions via video, so I encourage anyone to practice with that. Use exaggerated facial expressions like bigger smiles, and exaggerate the affect behind emotion words. I think that’s really helpful for getting kids engaged,” Dr. Woods says.

Although telemental health sessions with young children can be uniquely challenging for care providers, a little preparation can smooth over difficulties and make these sessions just as productive and rewarding as any other. We encourage all behavioral health professionals to use these tips to improve the quality of their virtual care sessions with children!


Looking for more information about mental health issues faced by children and teens? Here are a few more blog posts you might enjoy!