To Proceed Via Telehealth or Not? Considerations for Pediatric Anxiety and Related Disorders Beyond COVID-19

Abstract

The COVID-19 pandemic accelerated a widespread shift to telehealth among mental health professionals to prioritize both providers’ and clients’ safety. Telehealth is likely here to stay; however, there is limited practical guidance for clinicians about how to make decisions regarding who should proceed with care via telehealth versus in-person. There also is virtually no data on the effectiveness of hybrid approaches to care; yet this can be an attractive option with potential clinical benefit. This paper provides practice-informed guidance to support shared clinical decision-making between clinicians and families to decide whether to engage in therapy services in-person or via telehealth. We specifically focus on decision-making guidance relevant for youth with anxiety or related disorders, given the unique implications of telehealth for these youth. Guided by the three-legged stool of evidence-based practice, we discuss how clinicians can use principles of shared decision-making to inform clinical recommendations about treatment modality.

Theavailability and accessibility of telehealth for mental healthcare changed dramatically in the wake of the COVID-19 pandemic, which accelerated a widespread shift to telehealth among mental health professionals to prioritize both providers’ and clients’ safety (Gilbert et al., 2020). As COVID-19 restrictions relaxed, many providers returned to offering at least some in-person services, with “hybrid” (telehealth and in-person) services also available (Kayser et al., 2021). While there is some uncertainty about how well-supported telehealth will remain by regulations and payers following the expiration of emergency orders (Haque, 2021), mental health services via telehealth are likely here to stay, given their many benefits (Frank et al., 2021, Madigan et al., 2021, Riley et al., 2022). However, despite a rapidly burgeoning literature around telehealth’s effectiveness and potential to increase engagement in care, there is virtually no data on the effectiveness of hybrid approaches to care (i.e., treatment courses that include a mix of both telehealth and in-person services for a single client) or guidance about what youth characteristics should suggest use of one modality over another. Thus, with the increasing resumption of in-person therapy services alongside the continuation of telehealth, clinicians are left with little guidance as to how to make recommendations about whether a given client would most benefit from therapy services delivered via telehealth versus in-person versus hybrid.

In the absence of an empirically derived roadmap, we seek to provide practice-informed guidance to support shared decision-making between clinicians and families seeking services for pediatric anxiety and obsessive-compulsive disorder (OCD) to decide whether to engage in therapy services in-person or via telehealth. Our recommendations throughout this article emphasize the importance of decision-making that integrates clinical judgment and expertise about which youth are most likely to benefit from one modality over another alongside client and family perceptions of treatment modalities and logistical barriers to in-person or telehealth services. We focus on youth with anxiety and OCD for two reasons. First, these conditions represent some of the most common mental health conditions in youth (Bitsko et al., 2022). Second, given the nature of psychotherapy for youth with anxiety or OCD (i.e., exposure-based cognitive behavioral therapy or “exposure therapy”), clinicians experience unique challenges when considering the pros and cons of a telehealth approach that must guide considerations.

Unique Telehealth Considerations for Pediatric Anxiety and OCD

Telehealth offers unique benefits and relative advantages over in-person care for youth with anxiety and OCD. Notably, exposure therapy, the leading psychosocial intervention for anxiety and OCD (Higa-McMillan et al., 2016), can be enhanced over the telehealth platform. Exposure therapy involves gradually coaching youth to face structured, feared situations designed to help them learn that feared outcomes may not come true as expected (Craske et al., 2014). A benefit of conducting exposures through telehealth is that clinicians have an opportunity to access feared stimuli that are not available or are hard to recreate in the therapy office, such as in-home contaminants, showers, etc. (Candelari et al., 2021). Telehealth also facilitates clinician ability to observe the client in their home environment and obtain a direct view into how the family functions in their naturalistic setting, which can facilitate tailoring of exposure practice. Designing exposures in a client’s natural environment has the potential to enhance effectiveness and generalized learning in the setting where clients may experience more severe symptoms or encounter more triggers. For example, a telehealth-facilitated exposure for a client with concerns about contamination by a sibling can involve coaching them to practice entering the sibling’s space, touch “contaminated” items, and/or engage with the sibling directly. This may be a more potent exposure, than say, bringing the sibling into an in-person session in the clinician’s office. Additionally, telehealth allows clinicians to be able to enter other feared environments more easily than if they had to travel in person. For example, a clinician can use telehealth to coach a youth exhibiting school refusal due to separation anxiety to gradually engage in behaviors that approach leaving caregivers behind at home to attend school, and the clinician can simultaneously model unemotional directives for caregivers to facilitate exposures. Finally, youth who experience anxiety about attending a session may find it less stressful to attend via video than meeting someone face-to-face; thus, telehealth can serve as a step to engage youth in treatment who might otherwise drop out of care.

On the other hand, exposure therapy can be complicated over video conferencing platforms (Sheu et al., 2020), requiring thoughtful adaptation from traditional in-person protocols (Khan et al., 2021). Given that exposures are, by definition, at least somewhat distressing to clients, many youth may have reservations about attending therapy sessions; avoiding sessions may be easier over telehealth. It can also be difficult to conduct exposures that require youth to venture beyond the comfort of the home setting to approach situations and/or objects that induce a great amount of fear, such as a client with social anxiety approaching someone in public to ask for directions. Additionally, in our experience, caregivers may not provide as much oversight to therapy attendance for telehealth sessions, as youth may log on to video conferencing platforms themselves, in contrast to in-person sessions, which typically necessitate caregivers accompanying youth to sessions and ensuring their attendance. Telehealth also can serve as either an extra stressor (e.g., for socially anxious youth who may not want to appear on camera) or a way to avoid in-person interactions or other feared situations. It also affords youth a “choice” to remain off-camera or only show parts of their face on-screen. Finally, even in the most optimal environments for telehealth settings, telehealth makes it more difficult to read subtle, nonverbal cues that clinicians often rely on to titrate the difficulty of exposure practice.

Finally, although understudied, an intentional hybrid model that incorporates in-person and telehealth services may allow for impactful clinical gains in some cases. For example, a client with social anxiety may attend sessions in person a few times to develop rapport and conduct initial exposures to social situations, and then transition to telehealth for skill consolidation and relapse prevention. Alternatively, clinicians might design treatment plans that include primarily telehealth sessions with at least once-a-month sessions in person. In-person sessions could focus on teaching new content and office-based exposures, with telehealth sessions used to coach practice within the child’s natural environment.

To aid clinicians in making decisions with this population about how and when to proceed via telehealth or not, we offer practice-based recommendations guided by the three-legged stool for evidence-based practice (EBP) in psychology (Spring, 2007). We briefly (1) review the research evidence for the efficacy of psychotherapy via telehealth services, as compared to in-person services (“leg” 1), (2) discuss how clinicians’ experiences and expertise can be harnessed to make decisions about the modality of services (“leg” 2), and (3) discuss factors that may shape client treatment preferences for families of youth with OCD and severe anxiety (“leg” 3). Following this, we discuss how clinicians can integrate these components alongside principles of shared decision-making for youth mental health care (e.g., Langer & Jensen-Doss, 2018) to inform clinical recommendations about whether to provide mental health care services to youth with anxiety and OCD via telehealth or in-person. We conclude by discussing key gaps in research and future directions for decision-making regarding telehealth care.

Stool Leg #1: How Can Research Evidence Support Decision-Making Around Treatment Modality for Youth With Anxiety or OCD?

Randomized controlled trials (RCTs) comparing psychotherapy delivered via telehealth versus in person for clients of all ages with anxiety and related conditions generally demonstrate comparable treatment response between the two modalities up to 12 months posttreatment (Krzyzaniak et al., 2021). Existing studies focused on youth generally find telehealth services to be efficacious, with effect sizes comparable to in-person services (e.g., Storch et al., 2011, Vogel et al., 2014). The few studies that directly compared telehealth and in-person services specifically for youth with anxiety and OCD through randomized trials are also promising. Comer et al. (2017) randomized 22 four- to eight-year-old children with OCD to video-delivered or clinic-delivered family-based cognitive-behavioral therapy (CBT). They found no significant differences between conditions on any clinical outcomes (Comer et al., 2017). Turner et al. (2014) performed a randomized controlled noninferiority trial comparing telephone and face-to-face CBT for 72 adolescents, aged 11 to 18, with OCD, and also found equivalent outcomes (Turner et al., 2014). Beyond symptom-based outcomes, multiple studies find significant increases in attendance rates that coincide with a complete transition to telehealth (Childs et al., 2021, Nicholas et al., 2021, Silver et al., 2021). Increased attendance rates via telehealth can also mean fewer pauses in treatment when a family has transportation issues, becomes sick, or has a COVID exposure from other family members or classmates.

In sum, the treatment literature provides tentative support for equivalent effectiveness of in-person versus telehealth-delivered intervention for youth with anxiety and OCD. However, prior studies were limited by small sample sizes and limited client diversity (predominantly White and of high socioeconomic status; Comer et al., 2017) or unreported demographics (Turner et al., 2014). Critically, small sample size limits identification of treatment moderators; thus, virtually no data exists to suggest whether some youth are more likely to benefit more from one modality or the other. RCTs also require clients and families to agree to be randomized to either telehealth or in-person treatment, which limits generalizability of findings; for example, Turner et al. (2014) reported that 11 families declined to participate because they did not want to be allocated to the telephone condition (8 families) or the in-person condition (3 families). In addition, no data yet exist to support a hybrid approach due to a lack of research in this area (Comer, 2021). Thus, aside from knowing telehealth may benefit youth, the research evidence is not yet advanced enough to support definitive decision-making around treatment modality recommendations. Given this lack of research, it becomes especially important for clinicians to consider the two other legs of the EBP stool to guide decision-making in this area.

Stool Leg #2: How Can Clinical Expertise Support Decision-Making Around Treatment Modality for Youth With Anxiety or OCD?

Clinical expertise refers to a combination of clinician experience and judgment. This expertise typically provides complementary guidance alongside the other stool legs to inform treatment recommendations. As noted above, stool leg #2 plays an especially important role in making recommendations about optimal treatment modality, as the research evidence is not yet robust to inform personalized recommendations. While data on clinical expertise regarding telehealth with pediatric anxiety and OCD is limited, a recent survey of expert clinicians described perceiving telehealth to be more feasible for those with milder OCD compared to those with more severe symptoms; these clinicians also cited the greatest concerns about delivering telehealth to youth versus adult clients (Wiese et al., 2022). Thus, published wisdom suggests that youth with more severe symptoms or who are younger may benefit more from in-person treatment than telehealth.

This small body of literature also aligns with our clinical experiences providing telehealth and hybrid services in a pediatric specialty anxiety clinic dedicated to serving youth on public insurance in the Northeast United States. Table 1 presents an overview of how factors related to symptom presentation and motivation can impact response to each modality. Our experience suggests that certain anxious clinical presentations benefit sharply from in-person support and interactions (e.g., selective mutism, social anxiety). While clinicians can make telehealth adaptations for exposures that facilitate social interactions and engagement (Khan et al., 2021), many youth with social anxiety or difficulty communicating with others will ultimately benefit from in-person support to coach brave practice interacting with others.

Table 1.

Clinical Considerations for Determining the Optimal Treatment Modality for Youth with Anxiety and OCD

Factors to Consider	Guiding Questions	If Yes…
		Telehealth Indicated	In-Person Indicated
Factor #1: Symptom Presentation and Motivation
Clinical presentation	Do the youth’s anxiety symptoms (e.g., selective mutism, social anxiety, high acuity) suggest in-person support may be needed for successful engagement?		X
	Are there exposures that would have more ecological validity if conducted via telehealth in the home setting vs in-person?	X
Youth age	Does the client age suggest they would benefit from structural supports to successfully engage in session?		X
Co-occurring symptoms	Does the client present with symptoms of depression or attentional difficulties that impact engagement via telehealth?		X
Motivation	Does the client appear to have mixed or low motivation for treatment?		X
	Is the family sufficiently engaged in treatment to implement behavioral supports to foster engagement in telehealth care?	X
Factor #2: Client Perception of Effectiveness and Preference
Opinions of effectiveness	Does the client and their family perceive that in-person services will be more effective for them than telehealth?		X
Preference	Does the client or family have a strong preference for telehealth?	X
Factor #3: Logistical barriers
Transportation barriers	Does the family live a far distance from the clinic?	X
	Does the family have limited access to reliable transportation?	X
	Does the family have to rely on multiple public transportation systems to reach the clinic?	X
	Does the clinic setting have resources to provide free transportation vouchers or on-site childcare?		X
Space availability	Does the client have a quiet and private place for a telehealth session?	X
Scheduling conflicts	Does the client frequently cite last-minute barriers (e.g., activities) that lead to inconsistent in-person attendance?	X
	Does the client struggle to prioritize being at home for a telehealth session (e.g., attempts to attend session in the car on the way home from an activity)?		X
Caregiver availability	Do the caregivers have a work schedule that prevents them from consistently being able to provide transportation?	X
	Are caregivers present in the home and will be available to participate in and/or provide oversight for telehealth sessions?	X
Technology	Does the client have access to a laptop or computer?	X
	Does the family have a reliable internet connection?	X
Childcare for siblings	Does the family have access to childcare for the client’s siblings?		X
Factor #4: Client and Family Comfort
COVID-19 rates	Do current transmission rates suggest a need to switch to telehealth?	X
	Is anyone in the family immunocompromised or have other health conditions that increase their vulnerability to COVID-19?	X
Family values	Is the client and family willing to wear masks if required for in-person sessions?		X

Our experience also suggests that youth with more severe symptoms, those with comorbidities that limit engagement (e.g., attention difficulties, depressive symptoms), and those whose caregivers cannot provide adequate oversight to telehealth care typically struggle to benefit maximally from treatment via telehealth. We have seen youth with more severe symptoms or mixed motivation for treatment struggle to develop rapport over the telehealth platform but engage more effectively with therapy once services transition to be in-person. In addition, youth with attention difficulties receiving telehealth services may further distract themselves (e.g., playing games on other tabs online) and struggle to engage with the therapist via telehealth platform. While strategies such as use of visual schedules shared remotely, rewards, and encouraging caregiver oversight can certainly support youth engagement via telehealth (e.g., Seager van Dyk et al., 2020), these are not always feasible (e.g., the caregiver is responsible for multiple children in the home) or are insufficient to promote treatment progress (e.g., attention difficulties persist and interfere with care despite efforts to structure the telehealth encounter). Such scenarios may indicate the potential benefit of in-person care. In contrast, some youth may exhibit most of their symptoms in the home setting as compared to the clinic, such as when specific OCD contamination symptoms are present primarily in the home, or a youth experiences a lot of fear about going in certain parts of their home without a caregiver present. In these cases, there may be clear advantages to the telehealth modality to facilitate in-vivo coaching of brave practice in the ecological setting where symptoms occur. Thus, clinical conceptualization and judgment about how youth are likely to respond differentially to intervention strategies as a function of telehealth versus in-person care should factor into clinical recommendations, despite the lack of clear empirical guidance.

While clinical judgment is critical, it also is known to be susceptible to bias (Stewart et al., 2018). For example, a clinician’s individual perception of the effectiveness of telehealth may or may not align with published effectiveness data. In a recent study of clinician perceptions of telehealth, only 82% reported feeling as though remote therapy can be as effective as in-person therapy (Shklarski et al., 2021), while another study found that clinicians felt significantly less positive about telehealth effectiveness than did their adolescent clients (Nicholas et al., 2021). Thus, while the importance of clinical experience and judgment cannot be understated, it must be used in conjunction with the third leg of the EBP stool.

Stool Leg #3: How Can Client Preferences, Characteristics, and Values Support Decision-Making Around Treatment Modality for Youth With Anxiety or OCD?

The principles of EBP recognize that both clinicians and clients have expertise to bring to the table (American Psychological Association, 2006). An emphasis on client and family preferences (e.g., beliefs, experiences, environmental contexts) is the foundation for collaborative, shared decision-making about treatment and the modality in which it is delivered to obtain positive therapeutic outcomes (Langer & Jensen-Doss, 2018). This concept of collaborative decision-making is particularly relevant when considering telehealth versus in-person care for youth with anxiety and OCD, given the limited research data and known biases associated with clinical judgment alone. There are many facets of a family’s background, preferences, environmental context, and values that can and should inform treatment delivery. Here, we focus on three key factors likely to be of relevance to shared decision-making processes around treatment modality: (a) client and family perceptions of how effective telehealth will be, (b) logistical and environmental barriers to either in-person or telehealth care, and (c) client and family comfort with in-person sessions in the wake of the COVID-19 pandemic.

Perceptions of Effectiveness and Preference for Telehealth

Understanding each family’s preferences related to telehealth and their rationale is critical to guiding discussions about the optimal modality for a given youth. Overall, research to date has demonstrated that families report comparable satisfaction and rapport with their therapist in both telehealth and in-person sessions (Jenkins-Guarnieri et al., 2015). However, for clients with OCD specifically, evidence of telehealth effectiveness has been mixed, with some clients indicating that telehealth appointments are less helpful and others indicating being equally satisfied with telehealth and in-person treatment (Wheaton et al., 2021). Of note, some research has suggested that client perceptions of effectiveness of telehealth shift throughout the treatment process (Madigan et al., 2021), emphasizing the need for continued assessment of client preferences throughout the entire course of treatment (e.g., taking a flexible, hybrid approach). As seen from our own clinical experiences, families may be concerned about the effectiveness of telehealth due to youths’ ability to connect with the therapist over telehealth, their environment (e.g., multiple children in the family, challenges with childcare, lack of confidentiality), or the nature of the presenting problem (e.g., attention difficulties).

Potential Logistical Barriers

The client’s environmental context is also critical to consider. Clients and families face many logistical barriers to engaging in in-person mental health care, especially those from low-income and economically disadvantaged backgrounds (Green et al., 2020). It is important for clinicians to assess contextual factors that may influence in-person attendance such as the caregiver(s)’ work schedule(s), distance to the clinic, access to transportation, and childcare for siblings. Traveling to an in-person session can be a burden for families, especially those with caregivers who work long hours or are unable to take off from work. Additionally, there is a lack of mental health services provided in rural and underserved areas, meaning those with less access to transportation and more life stressors may also have more difficulty physically getting to sessions (Douthit et al., 2015). Families may have to travel several hours on public transportation within a city to attend their child’s mental health session, costing them hours of their day. Further, families with multiple children may have to navigate coordinating childcare and/or activities for the clients’ siblings and have difficulty participating in sessions if they must bring the client’s siblings. Clinicians ideally should help clients problem solve and provide resources when available (e.g., transportation passes, childcare in the clinic, case management services). However, extensive logistical barriers to in-person sessions may ultimately indicate the need for telehealth; delivering mental health services virtually has long been touted as a potential solution to logistical barriers to treatment engagement (Nelson et al., 2017).

That said, while telehealth shows promise for expanding access to quality care for those who may otherwise not have access, it comes with its own unique logistical challenges that require careful assessment. A youth’s access to a private space where symptoms can be discussed openly, an environment free from distractions and background noise, and ability to stay on video camera while completing exposures are all ingredients for successful telehealth experiences. Telehealth can compromise confidentiality, especially for those living in smaller spaces and/or with multiple family members. In addition, lack of access to a desktop computer or laptop can limit a client’s ability to engage fully in a telehealth session and be challenging for the clinician if they are unable to fully see the client and observe nonverbal responses (Abramowitz et al., 2019, Wolitzky and Telch, 2009). This is particularly relevant within exposure treatment, as clinicians often make exposure-enhancing adjustments through a three-dimensional perspective of the exposure environment, modeling calm body language and physical proximity to facilitate approach behaviors towards feared stimuli (Abramowitz et al., 2019, Wolitzky and Telch, 2009). Clinicians also facilitate many telehealth activities through screensharing; this utility is reduced when clients use a tablet or cell phone to join sessions. An unstable internet connection can also be disruptive; this is particularly true when conducting exposures where clinicians ideally should be able to provide live and immediate support. Unfortunately, it is often the same individuals who could most benefit from telehealth (i.e., those with lack of access to clinics and transportation) who face the most logistical barriers to benefiting from it, exacerbating existing disparities (Lamb et al., 2019, Ryan and Lewis, 2017). Thus, in such instances, more traditional strategies for facilitating access to in-person sessions (e.g., providing free transportation passes) may be indicated.

Comfort Level and Perception of Risk

Consideration of client comfort levels and perceptions of risk, particularly within an anxious population, is critical. While we intend for this work to support clinicians postpandemic, COVID-19 remains a threat, and we cannot ignore the possibility of future disease threat (e.g., Kayode et al., 2021). Clients will likely have different perceptions of safety based on their own lived experiences, values, and beliefs. Clients may have family members or may themselves be immunocompromised or have other health conditions that increase their vulnerability to COVID-19, leading to significant discomfort with in-person services. In addition to potential client and family health issues, a family’s values and beliefs about health and the pandemic itself can influence their comfort. These values may lead them to prefer in-person sessions or to exercise caution and request telehealth. Even something as simple as one’s beliefs around or comfort with wearing masks during sessions could influence a family’s decision as to whether to engage in in-person or telehealth treatment. Regardless of a family’s specific situation, it is important to assess and value their comfort level and perception of safety in the decision-making process of which therapy modality to utilize.

Integrating the Three Stool Legs of EBP to Support Decision-Making Related to Treatment Modality

Ultimately, we recommend that any final decisions should be guided by principles of shared decision-making in youth mental health care. Shared decision-making involves the youth, caregiver, and clinician in the decision-making process and emphasizes the importance of bidirectional information sharing, and systematic, collaborative discussion of the pros and cons of telehealth versus in-person sessions (Langer & Jensen-Doss, 2018). Critical to shared decision making is the notion that clinicians and families can and should continuously revisit any initial decision to determine whether an alternative modality may better serve a youth’s treatment needs at a given point in treatment. Table 1 provides an overview of how factors discussed that are related to: (a) symptom presentation and motivation, (b) client perceptions of modality effectiveness and preference, (c) logistical barriers, and (d) client comfort, described above, can guide decision-making about the ideal treatment modality for a given child in the absence of clear empirical guidance.

In some cases, clinicians may make strong recommendations for one modality over another based on youth symptom presentation and motivation (Factor #1). For example, given a potential relationship between symptom severity and engagement (Madigan et al., 2021), a clinician may strongly recommend in-person treatment, at least initially, when working with highly symptomatic clients or those with presentations that theoretically may benefit more from in-person care, such as those with social anxiety difficulties or attention comorbidities. While collaboratively discussing the pros and cons of initiating treatment via telehealth, clinicians should share evidence that overall, telehealth was measured to be as effective as in-person services (Frank et al., 2021, Riley et al., 2022), and that there is lack of rigorous empirical data about who is more or less likely to benefit from telehealth than others as a function of symptom presentation. At the same time, clinicians also should be forthcoming about their clinical experience with youth of similar presentations and their expectations for how they will progress via telehealth as opposed to in-person (e.g., that youth with more severe symptoms may benefit less from telehealth than in-person sessions).

In the absence of clearly compelling clinical information that guides a recommendation, client perceptions of telehealth effectiveness and references for modality of care (Factor #2), identified logistical barriers (Factor #3), and client/family comfort (Factor #4) should be weighed heavily into the decision-making process. Carefully listening to and considering family concerns about treatment modality and weighing these concerns against clinical judgments about what is in the best interest of the client on a case-by-case basis can guide this process. Regarding clients’ perceptions of effectiveness and preferences, clinicians can directly elicit treatment expectancies about one modality versus another and identify any concerns families have about each to guide additional discussion.

Regarding logistical barriers, clinicians also should carefully assess the client's access to appropriate technology and provide clear, explicit expectations for what makes a telehealth session successful (e.g., computer vs. phone to conduct sessions, presence of caregiver for a check-in at the start and/or end of sessions, minimal distraction, and a private location to attend sessions). It is the clinician’s responsibility to review and identify barriers, paying particular attention to barriers to confidentiality, and collaborate to find a potential solution (Madigan et al., 2021). If a private location cannot be assured, the clinician may err on the side of recommending in-person sessions over telehealth to optimize treatment success.

With respect to client comfort, if COVID-19 or other disease risk concerns arise in these initial discussions, clinicians can provide data on any evidence of on-site transmission of disease and explain the rationale for any institutional requirements (e.g., masks) that are designed to minimize the public health threat. It also is worth noting that a clinician's own level of comfort with working remotely and tolerance for COVID-19 exposure can influence the decision to proceed with telehealth over in-person services. A survey from August 2020 found that 81.1% of clinicians were comfortable working from home, while 63% agreed that telehealth sessions were significantly more emotionally draining (Shklarski et al., 2021). While data on updated perceptions are needed as we progress through the course of the COVID-19 pandemic, convenience of work settings and precautionary measures remain strong influences on decision-making between telehealth, in-person, and hybrid services. Clinicians must exercise caution to ensure that their own preferences for remote work do not override what clinically is in the best interests of a youth’s care.

So far, we primarily discussed considerations for modality over a course of treatment. However, clinicians also occasionally need to make real-time decisions about how to proceed with scheduled in-person sessions when unanticipated events occur (e.g., clinician or client illness, local surges in COVID-19 case rates). In many instances, the flexibility afforded via hybrid care allows clinicians to convert in-person appointments to telehealth at the last minute. When a last-minute switch is made, clinicians should remind youth and their caregivers about best practices with supporting telehealth sessions (e.g., ensuring the youth has a private space to meet, that a caregiver is present in the event of risk, etc.) before confirming a switch. If an optimal telehealth environment is not feasible, canceling the session rather than converting to telehealth may be indicated.

Continuous Assessment to Guide Revisiting Initial Decisions

Clinicians should anticipate that their recommendations will not always align with clients’ values and preferences, and that logistics might interfere with the recommended modality of treatment. Should a family elect to proceed with a modality against a recommendation, clinicians should notify families that they may revisit this decision later on in treatment. They also should document this choice explicitly in the client’s chart. In addition, while clinicians and families will make an initial determination of treatment modality, they should revisit this decision throughout the course of treatment. For example, if a child is not progressing on telehealth due to a lack of focus or avoidance of feared stimuli during exposure practice, this likely indicates that in-person services would be more beneficial for this child; however, their family’s level of anxiety about COVID-19 might lead them to decline recommendations for in-person services and elect to remain virtual despite these notable barriers to treatment. Technology issues only may become apparent over time, which also may prompt revisiting initial decisions. While clinicians should always utilize shared decision-making, they should prioritize client preference if there are no safety concerns and there is nothing about the clinical presentation (e.g., selective mutism) that strongly suggests one modality is preferred over another. Clinicians can leverage natural opportunities to discuss treatment (e.g., when updating treatment plans, beginning a new type of exposure, changes in COVID-19 transmission rates, client illness, increase in symptom severity) to continuously revisit the decision to conduct services in-person or via telehealth.

In addition, clinicians working with anxious youth should carefully monitor for the presence of avoidance behaviors or other clinical symptoms that might indicate the potential benefit of a modality switch. For example, a clinician who notices their client continuously canceling in-person appointments due to fear of taking the bus to therapy might suggest an initial switch to telehealth to stabilize anxiety symptoms and then gradually support the youth to conduct graduated exposure with taking the bus to switch to in-person sessions. Alternatively, a clinician might prioritize altering modality to in-person care for a client who consistently communicated only via the chat function of a telehealth platform due to fears of being overheard by a family member.

Finally, it is worth noting that delivering therapy via telehealth and in-person services each requires unique competencies. As both modalities are likely to remain relevant for clinicians in the foreseeable future, clinicians might also weigh factors related to maintaining a mix of telehealth and in-person visits on their caseload to ensure maintenance (or development, for trainees) of skills in both contexts. A desire to maintain a caseload mix may serve as another decision-making factor for some clinicians in cases where there are no clear client-level indications that one modality is preferable over the other.

Conclusion

We presented guidelines for supporting clinicians to make shared decisions with families about choosing between in-person and telehealth mental health services for youth with anxiety and OCD. Information presented takes into consideration the available research evidence on the efficacy of in-person versus telehealth services, clinical judgment, and client preferences, thus addressing the three “legs” of EBPs. With limited research evidence regarding the effectiveness of in-person versus telehealth services to date, we suggest that treatment modality decisions prioritize clients’ preferences, but only after clinicians present them with their clinical judgment regarding best outcomes so that clients and families may make the most informed decisions. Should clients choose a treatment modality that does not converge with clinician recommendations, clinicians should document this and regularly re-visit discussions about treatment modality. Of course, given the ongoing COVID-19 pandemic, clinicians must continuously consult current epidemiological research to inform best practices for enhancing the safety of in-person therapy sessions or to consider a temporary shift to telehealth.

While treatment delivered via telehealth yields positive outcomes for youth with anxiety or OCD, there are clear gaps in the literature to guide optimal clinical decision-making in this sphere. To promote effective collaborative decision-making between clinicians and families, further research is needed in several key areas. First, direct comparisons of treatment modality (i.e., telehealth, in-person services, or a hybrid approach) for youth with OCD and severe anxiety can inform understanding of which modality yields better outcomes. Second, this is an area ripe for practice-based research to learn from clinicians about how they make decisions in this area and examining how these decisions relate to client outcomes. Third, it may be fruitful to explore the ideal frequency with which clinicians should check in to reassess treatment modalities, especially in hybrid models or when clients elect to initiate a modality against clinician recommendations. Fourth, researchers should prioritize examining moderators that impact treatment outcomes including logistical barriers, symptom severity, and client preference, to help refine the clinical recommendations outlined above. Finally, to inform clinical training and best practices for maintaining competencies in delivering both telehealth and in-person services, researchers should study whether there is a minimum number of clients that clinicians need to see in person or via telehealth over time to maintain skills within both modalities.