Successes, challenges, and opportunities in providing evidence-based teletherapy to children who have experienced trauma as a response to Covid-19: A national survey of clinicians

Abstract

While teletherapy is not a new phenomenon, most clinicians have not been trained and do not routinely practice it. The current study was designed to ascertain challenges and opportunities presented by the widescale usage of teletherapy especially for traumatized children, which was necessitated by the COVID-19 pandemic. Two hundred and fifty clinicians across the United States providing teletherapy to traumatized children completed an online survey. Results revealed that many logistical aspects of treatment were perceived to be easier when implemented remotely. Some clinical aspects of care were also perceived to be easier, notably engagement with caregivers. Developing rapport, assessing emotions, and keeping children’s attention, however, were perceived as more challenging. Child characteristics such as age, attention span, and screen fatigue were viewed as creating challenges. Most clinicians had not received training in relevant topics for teletherapy and were eager to receive such training. These results suggest many avenues for refining and fine-tuning remote mental health services especially for children.

1. Introduction

In the Spring of 2020, the COVID-19 pandemic rapidly spread throughout the United States. This resulted in widespread and immediate shuttering of educational, recreational, retail, and human services throughout much of the country, including immediate cessation of in-person mental health treatment. Consequently, the pandemic created a whole new set of logistical and financial barriers for families with children receiving or in need of mental health treatment, as well as for treatment providers themselves. The Associate Commissioner of the Children’s Bureau noted that, “The COVID-19 pandemic has created unprecedented challenges for our health and human services systems in serving our most vulnerable families, children, and youth” (Milner, 2020).

Not only did COVID-19 interrupt treatment, but it also contributed to increased anxiety, fear, sadness, and uncertainty for children and their families and thus introduced additional stressors and trauma into the lives of already vulnerable children (Shah et al., 2020). In one study, parental fear and anxiety brought on by COVID-19 was associated with greater emotional distress and poorer quality of life for children (Adibelli & Sümen, 2020). In a national survey, researchers found worsening mental health for parents occurred alongside worsening behavioral health for their children (Patrick et al., 2020). In a recent literature review, researchers concluded that COVID-19 is likely to exacerbate existing mental health problems in children (Waddell et al., 2020).

In response to the ongoing – if not elevated – need for mental health treatment in children and families, service providers adjusted on the fly to provide continuous care under extremely uncertain circumstances. Almost overnight, teletherapy became the primary means of service delivery for most providers even though many had never or only sparingly used it up until then (Burgoyne & Cohn, 2020). This shift in treatment modality was facilitated through formal executive orders and regulatory changes that supported teletherapy, relaxed HIPAA standards, and facilitated practice across jurisdictions (Bell, 2020). This was crucial for implementing teletherapy quickly, with currently available technology, and to clients in need regardless of their location or client status (Bell, 2020). In the early part of 2020, there was a near uniform transition to remote mental health treatment.

Teletherapy is not a wholly new phenomenon as some providers have been offering this service on an as-needed basis to clients who for a variety of reasons cannot easily attend in-person treatment such as individuals with a disability that precludes travel or those who are geographically remote or for private pay clients who prefer the convenience and other benefits of teletherapy. The benefits of teletherapy for these populations has been touted by the U.S. Department of Health and Human Services (2016).

Moreover, there are data on the implementation and effectiveness of teletherapy specifically for children. In a recent meta-analysis of seven studies examining the effectiveness of speech and language interventions for children offered remotely, results revealed both remote and in-person participants made significant and similar improvements when treatment effects were measured through five of the six outcome measures (Wales et al., 2017). Teletherapy has been found to be effective for treating PTSD (Germain et al., 2009) as well as eating disorders (Mitchell et al., 2008). The American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues (2017) conducted a literature review of 250 studies testing teletherapy and concluded that there are no absolute contraindications for care delivered through this medium with youth, as long as children and youth do not refuse to attend.

There is even some promising data regarding trauma therapy offered via teletherapy. In one study, Jones et al. (2014) present a detailed plan for how clinicians can provide TF-CBT remotely, with a strong emphasis on planning and preparation for components of the treatment that may not easily translate to a remote setting. The authors concluded that interactive activities may need to be modified, clinicians must ensure that children and caregivers have access to the handouts, and certain relaxation techniques that rely on pinwheels and bubbles need to be made available in advance. Stewart, Orengo-Aguayo, Gilmore, et al. (2017) offered TF-CBT via telehealth to four children and found high participation rates and meaningful reduction in measured symptoms. By the end, none of the children met the diagnostic criteria for PTSD. Stewart, Orengo-Aguayo, Cohen, et al. (2017) present the results of a pilot study in which TF-CBT was implemented remotely. They concluded that their findings were promising in showing that treatment effects of remote TF-CBT are comparable with TF-CBT delivered in person.

More recently, the New York City-based Clinicians in Child Welfare (CCW) released a white paper presenting the results of a survey of children in the foster care system receiving teletherapy and their caregivers (Konigsberg, Goldstein et al., 2020). The study found that teletherapy was perceived as helping families meet their treatment needs and 76 % reported it even allowed them to connect to new supports. Participants identified that safety, convenience, and the ease of making and keeping appointments all increased due to telehealth. Although some of the narrative responses indicated challenges related to privacy and technology, such as the need for devices or Wi-Fi connectivity, the majority of participants responded that they were able to have privacy and to navigate technology related to teletherapy successfully. Over 75 % of participants in the survey reported that the frequency of services increased or remained the same after remote treatment was implemented. Overall, the children, and youth in foster care and their caregivers reported that teletherapy services were high-quality and beneficial to them.

These are encouraging findings in light of the consensus regarding the importance of trauma-informed care as well as trauma-focused interventions for children receiving mental health treatment. Trauma informed care means that service systems are oriented towards the recognition of the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and respond by fully integrating knowledge about trauma into policies, procedures, and practices (Brennen et al., 2019, Substance Abuse and Mental Health Services Administration, 2014). At the case level, trauma-informed treatment involves the three pillars of safety, connections, and managing emotions (Bath, 2008). The term trauma-focused intervention is used to refer to specific programs that are designed to address trauma-related symptoms directly in individuals. A review of trauma-focused treatments for adolescents identified five therapeutic foci: psychoeducation, coping skills, creating a trauma narrative, cognitive restructuring, and creating a post-treatment plan (Black et al., 2012). A more comprehensive set of 16 trauma treatment core components has been articulated by the National Child Traumatic Stress Network (n.d.).

Research has established that the negative impact of childhood traumatic stress can be significantly mitigated with trauma-informed mental health interventions and trauma-focused treatments. Several high-quality randomized controlled trials (RCTs) have demonstrated statistically significant and clinically meaningful reduction in trauma symptoms and improvement in functioning following participation in trauma-focused treatments such as Alternatives for Families-CBT (AF-CBT) (Kolko, 1996), Trauma-Focused CBT (TF-CBT) (Deblinger et al., 2011) and Eye Movement Desensitization and Reprocessing (EMDR) (Moreno-Alcázar et al., 2017). These positive effects have been found to be sustained months post treatment (Gutermann et al., 2017).

Despite the promising picture emerging about the benefits and effectiveness of teletherapy for children who have experienced trauma, much remains to be learned about the advantages and disadvantages of this method of treatment delivery. To address this gap, the current study was developed to survey a national sample of clinicians providing teletherapy to children who have experienced trauma. The advantages and disadvantages of teletherapy for traumatized children are explored in this study from the vantage point of the front-line clinicians providing this treatment. Their unique and highly salient perspective has not yet been incorporated into the knowledge base and the current study was designed to address this gap. In particular, they were asked about four aspects of their experience.

The first area of assessment was how clinicians perceived teletherapy to be impacting the treatment they provided to children who had experienced trauma. Building from prior studies that found that teletherapy could be provided in a high-quality manner, (e.g., Stewart, Orengo-Aguayo, Cohen, et al. (2017), we aimed to identify clinicians’ perception of the advantages and disadvantages of different components of the treatment that may need to be modified in future remote service delivery plans. Thus, we asked about the impact of teletherapy on four aspects of treatment. The first was logistical considerations (such as scheduling and attendance), which emerged in the white paper as strengths of teletherapy and were included here as an attempt to replicate these important findings in a more systematic fashion. The second focus was on quality of different components of treatment (including rapport building and assessing emotions). Quality of care is essential to consider in any study of mental health services and has been perceived by the recipients of treatment to be comparable (Konigsberg et al., 2020). Questions about quality of care were examined here from the perspective of the clinician, a yet unexamined perspective in the study of telehealth. The third component, was specific challenges regarding implementing an evidence-based model, to build on the work of the small-scale studies of Stewart et al. (2017) and the lessons learned from Burgoyne and Cohn (2020) in which clinicians providing telehealth reported that reading a client’s emotional signals was challenging for them. The fourth focus was on specific challenges regarding the trauma narrative, an essential component of most trauma-informed treatments and one that is likely to need some adaptation for remote sessions (Stewart et al., 2017).

The second area of assessment was on two factors that clinicians might perceive to be impacting teletherapy; specifically (1) technical issues and (2) child characteristics We examined technical issues (such as software issues, Wi-Fi access, lack of privacy) as they are unique and specific to telehealth and emerged as problematic in the Konigsberg et al. (2020) survey of recipients of telehealth. Characteristics of the child that may increase challenges for the clinician providing teletherapy (including age, status on the spectrum, gender) were included in this study based on prior research indicating that these factors can play a role (Burgoyne and Cohn, 2020, Konigsberg et al., 2020). Although these factors are not easily modifiable, we believed that these data would be useful in helping clinicians consider when and for whom teletherapy would be most effective.

The third area of assessment was training received and desired by clinicians, specifically on teletherapy. Although the pandemic necessitated a swift and immediate transition to remote treatment, clinician post hoc feedback on the areas that warranted more training will help enhance effective ongoing implementation of telehealth. The topics selected were drawn from prior writing on this topic such as Burgoyne and Cohn’s (2020) observations about the impact of clients seeing into the home of the therapist.

Lastly, we assessed the clinicians’ experience of stress as well as their challenges in implementing self-care during the pandemic. Research has established that the stress level and coping resources of clinicians can significantly impact the quality of services provided by them to their traumatized clients (Deblinger et al., 2020).

2. Material and methods

2.1. Participants

The study was approved on April 1, 2021 by St. John University’s Institutional Review Board (reference number: IRB-FY2021-408.) Two populations were drawn upon for the sample of this study. Each of which was comprised of mental health clinicians providing evidence-based trauma-informed and/or trauma-focused treatment to children who had traumatic experiences. The first was mental health clinicians working in child welfare agencies in a large metropolitan area. Based on their job responsibilities it was understood that these clinicians would have experience providing teletherapy to children who have experienced trauma. This was based on the fact that all children in foster care have experienced at least one form of maltreatment (which is a traumatic experience) and have also been removed from home and placed in foster care (which is also a traumatic experience). To gain access to these clinicians, the directors of mental health in all 23 child welfare agencies in the city were contacted, provided information about the study, and asked to provide contact information for their agency’s clinicians. Two agencies did not respond to several e-mail and phone queries, one agency offered to distribute the survey directly to its clinicians and 20 provided the requested information resulting in an 87 % response rate for agencies. From these 20 agencies, contact information for 231 clinicians was provided, 182 of whom completed the survey, resulting in a 79 % response rate of agency clinicians. Each of these clinicians confirmed in the screening question in the survey that since the pandemic they had provided teletherapy to children who had experienced trauma.

The second population was derived from the internet listing of all clinicians who had been certified in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) (https://tfcbt.org/members/) as of April 2021. TF-CBT certification is achieved through extensive coursework, practice with clients, case consultation, and vignette-based assessments. It was deemed likely (but certainly not guaranteed) that such clinicians would have experience providing teletherapy to children who have experienced trauma. A random selection of 200 clinicians from the list was generated (selecting every 21st name). Of these 200 clinicians, 113 had inactive/incorrect e-mail addresses, and/or did not provide this service (i.e., were administrators, did not treat children, or did not provide teletherapy). Of the 87 remaining clinicians, 68 completed the survey, resulting in a 78 % response rate. Each of these clinicians confirmed in the screening question in the survey that since the pandemic they had provided teletherapy to children who had experienced trauma.

While all clinicians responded affirmatively that they were providing teletherapy to children who had experienced trauma, exactly what kind of teletherapy was not asked about (i.e., synchronous, audio only, etc.) However, based on the authors’ knowledge of mental health services provided by the clinicians working with the children in foster care and based on the comments of the other sample of clinicians, it is assumed that most, if not all, were providing synchronous therapy with both audio and video components.

2.2. Methods

Once the contact information was obtained, emails were sent individually to each clinician, explaining the purpose of the study, informing them that the study was approved by a university IRB, inviting them to go to a link to complete the survey via Qualtrics, and letting them know that they will have a 1-in-10 chance of winning a raffle of a $100 gift card. Reminder emails and phone calls continued for ten weeks. Table 1 presents the sample characteristics.

Table 1.

Sample Characteristics (n = 250).

	N	%
Gender
Male	26	10.4
Female	218	87.6
Prefer not to say/Other	05	03.0
Highest education
Bachelor	03	01.2
Masters	209	84.3
Doctoral	36	14.5
Field
Social work	124	50.2
Psychology	48	19.4
Counseling	52	21.1
Other	23	09.3
EBT
TF-CBT	191	76.4
AF-CBT	13	05.2
EMDR	22	08.8
Other	64	25.6

Years Licensed M = 7.5, SD = 8.5.

The final sample was comprised of 250 clinicians across 28 states. The sample ranged in age from 24 to 75 (M = 37.9, SD = 10.8), was mostly female (87.6 %) and mostly had master level educations (84.3 %). Degrees were in social work (50.2 %), counseling (21.1 %), psychology (19.4 %) or other (9.3 %). Years licensed ranged from under one year to 51 years (M = 7.5, SD = 8.5). With respect to percent of cases seen remotely, about 5 % of the sample reported seeing fewer than 50 % of their cases remotely, 10 % reported that they were seeing about half their caseload remotely, and 85 % of the clinicians reported that they were seeing the majority of their clients remotely. About two thirds reported that they had ever implemented a trauma narrative with a child client prior to moving to remote services.

2.3. The survey

The survey included nine questions about background of the clinicians: (1) age, (2) gender (3) highest education, (4) field of study, (5) years licensed, (6) experience providing therapy to children in foster care (yes/no), (7) percent of clients in teletherapy, (8) evidence-based models provided, and (9) experience implementing trauma narration/imaginal exposure prior to the pandemic (yes/no).

To address research question one, four sets of items assessed the impact of teletherapy on treatment with children who have experienced trauma.

2.3.1. Perceived positive impact of teletherapy on logistics of treatment (5 items)

The survey included five questions about the perceived positive impact of teletherapy on the following logistical aspects of treatment: (1) safety, (2) access, (3) convenience, (4) scheduling, and (5) attendance. Response options were on a 5-point scale from 1 (Not at all) to 5 (Very much). A Cronbach’s alpha of these five items indicated strong internal consistency (alpha = 0.87) for creation of a summary score ranging from 5 to 25 (M = 17.1, SD = 4.8). A summary score was also created to count the number of logistical aspects of treatment perceived to be improved by teletherapy at least “a little.” Thus, the scores of 2 (a little), 3 (somewhat), 4 (much) and 5 (very much) were counted. This score ranged from 0 to 5 (M = 4.47, SD = 0.91).

2.3.2. Perceived impact of teletherapy on quality of care (7 items)

Two open-ended questions were included, one about how teletherapy made things easier for providing treatment to children who have experienced trauma, and one about how teletherapy made things harder. Prior to coding these responses, we removed responses that were not valid, defined as a numeric response, a missing response, or a response that was unrelated to the topic. The valid responses were submitted to content analysis guided by an inductive grounded theory approach (Berg, 2003, Straus, 1987) involving three steps: (1) one author (AB) read all of the responses to identify common themes, which formed the basis for the creation of an exhaustive list of categories; (2) two experts in the field (EB and MK) reviewed the list of categories and made suggestions for refinements; and (3) two authors (AB and KA) independently coded all responses into one of the final categories, achieving inter-rater reliability (Kappa = 0.88 for the first question and 0.92 for the second). Coding discrepancies were resolved through consensus. This three-step inductive coding process was applied to all open-ended questions. For the vast majority of open-ended responses, the study participants wrote in a single response. In the event that more than one response was written in, only the first was coded.

There were five closed-ended questions about the impact of providing teletherapy with children who have experienced trauma on the following areas: (1) rapport with child clients, (2) rapport with caregivers, (3) participation of caregivers, (4) child’s ability to feel supported by clinician, and (5) clinician’s ability to assess child’s emotional status. Response options were: 1 (Made things less challenging), 2 (No impact), 3 (Made things both more and less challenging), 4 (Made things more challenging). A summary score counted the number out of five that were perceived to be at least in part more challenging by counting the number of items with scores of 3 (both more and less challenging) and scores of 4 (more challenging). This variable ranged from 0 to 5 (M = 1.3, SD = 1.4).

2.3.3. Perceived impact of teletherapy on Evidence-Based treatment (EBT) (2 items)

Two open-ended questions were asked, one about how teletherapy made EBT more challenging for clinicians and one about how it made EBT more challenging for children. The same three-step inductive process of text analysis described above was used for coding these items, resulting in kappa = 0.88 for the first and 0.92 for the second.

2.3.4. Perceived impact of teletherapy on trauma narrations/imaginal exposure (5 items)

Five items asked about how teletherapy has impacted specific aspects of the trauma narration/imaginal exposure: (1) knowing when the child is ready to do it, (2) working on the components, (3) gauging the child’s emotional state, (4) knowing when the child needs a break, and (5) helping the child manage and process feelings. Response options were 1 (Less challenging), 2 (No impact), 3 (Both more and less challenging), and 4 (More challenging). A summary score counted the number out of five that were perceived to be at least in part more challenging by counting the number of items with scores of 3 (both more and less challenging) and scores of 4 (more challenging). This variable ranged from 0 to 5 (M = 3.2, SD = 1.9).

To address the second research question, two sets of items were included in the survey.

2.3.5. Perceived impact of technical and environment challenges on teletherapy (12 items)

Clinicians were asked to rate the degree of impact of six possible challenges to teletherapy, for the clinician and then for the child: (1) lack of reliable device, (2) lack of sufficient bandwidth/Wi-Fi, (3) lack of proficiency with software, (4) lack of privacy, (5) lack of quiet, and (6) interruptions. Response options were on a five-point scale from 1 (Not at all) to 5 (Very much). A summary score was created of all 12 items (each of the six potential problems for either the clinician or the child), ranging from 12 to 60 (M = 31.5, SD = 9.3), with an alpha coefficient of 0.89. A second summary score counted the number out of 12 (each of the six potential problems for either the clinician or the child) which were rated as “much” or “very much” a problem. This variable ranged from 0 to 12 (M = 3.8, SD = 2.9). Two additional summary scores were created, one reflected the count of the number out of six of the issues (each of the six potential problems for only the clinician) that were perceived to be at least “somewhat” of a problem for the clinician (M = 1.1, SD = 1.7) and the other was the number out of six (each of the six potential problems for only the child) that were perceived to be at least “somewhat” of a problem for the child (M = 4.8, SD = 2.7). In these two scores, the response that indicated the issues was “somewhat” of a problem (score of 3) were counted along with the scores that indicated the issue was “much” (score of 4) or “very much” (score of 5) of a problem.

2.3.6. Perceived impact of child characteristics on teletherapy (8 items)

Clinicians were asked about the impact of six child characteristics on teletherapy: (1) age, (2) gender, (3) attention span, (4) hearing and vision, (5) screen fatigue, and (6) being on the spectrum (which was not defined for the clinicians, allowing them to respond based on their own perspective and experience).

Response options were on a five-point scale from 1 (Not at all) to 5 (Very much). Another item asked which of three age ranges were more difficult for doing teletherapy (up to 6 years, 7 to 12 years, 13 years and older). This was followed by an open-ended question about why the selected age range was difficult. There was no theoretical basis for considering these different child characteristics as part of a single scale, and the lack of sufficient internal consistency supported not creating a scale or summary score for these variables.

To address the third research question, one set of items were included in the survey.

2.3.7. Training in teletherapy (10 items)

Clinicians were asked to describe training received as well as training desired in ten areas specific to teletherapy: (1) collaborative documentation, (2) dealing with hardware issues, (3) dealing with software issues, (4) developing rapport with child clients, (5) setting up a teletherapy space, (6) dealing with interruptions, (7) managing interpersonal boundaries, (8) being aware of triggers for child clients who see clinician’s home office, (9) being aware of triggers for child by being in own home during therapy, and (10) how to handle observations of problematic behavior in the home. For each of these training topics, respondents indicated whether they had received training (no/yes) and whether they wanted training (no/yes). Two summary scores were created, the first counted the number (out of 10) areas received training in (M = 4.1, SD = 3.5), and the second counted the number (out of 10) areas of desired training (M = 5.9, SD = 3.3).

The final research question was addressed with two sets of survey items.

2.3.8. Child and clinician experience with Covid-19 (7 items)

Clinicians were asked about their exposure to COVID-19 as well as exposure by their child clients: (1) child client contracted it, (2) anyone important to a child client contracted it, (3) anyone important to the child become seriously ill/die from it, (4) clinician contracted it, (5) anyone important to the clinician contract it, (6) anyone important to the clinician become seriously ill/die from it, and (7) any coworkers contracted it. Response options were 0 (No) or 1 (Yes).

2.3.9. Secondary stress and care of clinician (2 items)

Clinicians were asked two open-ended items. The first was how their secondary trauma/secondary stress has been affected by conducting teletherapy and the second was how COVID-19 has affected their self-care. The three-step inductive text analysis was applied to coding these two items, resulting in a Kappa of 0.96 for the first and 0.98 for the second.

3. Results

3.1. Perceived positive impact of teletherapy on logistics of treatment

Table 2 presents the distribution of scores indicating the extent to which teletherapy was perceived to be associated with improvement compared to in-person treatment in five logistical aspects of treatment. Between 65 % and 95 % of the sample perceived teletherapy to be associated with improvement of at least “a little” and between 11 % and 35 % felt that teletherapy was associated with “very much” improvement. Teletherapy was perceived to be most helpful with convenience, scheduling, and attendance, with about 60 % saying that they saw “much” or “very much” improvement in these areas. All but a few clinicians reported that logistics were improved in at least one area and 85 % reported that it was improved in at least four of the five areas asked about.

Table 2.

Percentage of Clinician Responses Regarding Perceived Impact of Teletherapy on Treatment.

Improve Logistics
	one	A little	Somewhat	Much	Very Much
Safety	30.2	18.0	31.0	09.8	11.0
Access	04.0	15.3	30.6	28.6	21.4
Convenience	02.4	06.8	22.1	33.3	35.3
Scheduling	06.8	07.2	25.3	30.5	30.1
Attendance	09.6	11.6	22.9	28.5	27.3
	Less Challenging	No Impact	More and Less Challenging	More Challenging
Rapport w child clients	03.6	13.2	54.4	28.8
Rapport w caregivers	24.2	17.3	38.3	20.2
Caregiver participation	42.4	10.0	32.8	14.8
Child feel supported	08.4	16.0	48.8	26.8
Assess child’s feelings	04.8	14.0	38.4	42.8
Impact on Trauma Narrative
Knowing child ready	04.3	24.7	32.5	38.5
Doing components	06.5	19.1	38.3	36.1
Gauging emotions	03.9	18.6	29.9	47.6
Timing breaks	13.8	31.0	27.2	28.0
Managing emotions	04.7	20.7	41.4	33.2

3.2. Perceived impact of teletherapy on quality of care

As presented in Table 2, 42 % of clinicians reported that participation of caregivers was less challenging with teletherapy than in-person treatment, between 30 % and 50 % felt that all five aspects of treatment were both more and less challenging as compared to in-person treatment, and the most challenging aspect was assessing the child’s emotional states. Approximately-one third of clinicians endorsed that it was more challenging to develop rapport with the child clients when conducting treatment via telehealth, for the child to feel supported, and to develop rapport with the caregivers. Only 6 % found none of the elements to be more challenging and 30.8 % found all five elements to be more challenging.

The two open-ended questions assessed how teletherapy made things easier and harder. With respect to how it was easier, there were 234 valid responses, 156 of which (66.7 %) said that teletherapy improved logistics of treatment (lack of transportation time and costs, easier to schedule sessions, and so forth), exemplified by comments such as “It has been easier for clients to keep appointments via tele-therapy,” and “Some clients have become more consistent in their attendance since telehealth services began.” Thirty clinicians (12.8 %) said that teletherapy was not easier, 24 (10.2 %) said that children were more comfortable in their home, such as the comment, “It's also given children a chance to be in their own safe space of their room, house, etc.” The remaining 24 comments (10.2 %) were miscellaneous and included that teletherapy encouraged clinicians to be more creative, that it allowed clinicians to have a better sense of the child’s homelife, that it allowed clinicians to join their clients in their on-line world, and that it allowed for better interdisciplinary collaboration.

In terms of how teletherapy made treatment harder, there were 231 valid responses. Almost half (44.2 %) said that it was harder to engage children because of distractions and issues with focus and attention, with comments such as, “It is more difficult for younger children to engage via telemental health due to attention span and formatting,” and “Sometimes there are distractions and patient needs to be redirected to the topics of discussion.” Thirty-six (15.6 %) said that privacy and lack of confidentiality were issues, with comments such as, “Lack of privacy makes it difficult to explore their negative experiences without the involvement of household members who may judge some of their sharing as 'inappropriate' or become uncomfortable themselves.” Thirty-four (14.7 %) said that the clinical work of emotionally connecting with the client was harder, exemplified in the following comment, “It has made it more difficult to establish rapport, pick up on nonverbal cues, and also makes both clients and me (as the therapist) more distractible. I feel like the emotional connection you get being in a room with a person is lost in teletherapy.” Technology issues were raised by 20 (8.7 %), and the remaining 39 responses fell into the miscellaneous category including comments that play and art were harder via teletherapy, that “teaching” is harder, and that some clients don’t turn the camera on.

3.3. Perceived impact of teletherapy on Evidence-Based Treatment (EBT)

Open-ended questions assessed how teletherapy makes EBT in particular more challenging for the clinicians and for the children. In terms of impact on clinicians, there were 211 valid responses. Of these, 45 (21.3 %) mentioned the trauma narration/in vivo exposure, with comments including, “Writing the trauma narrative for TF-CBT. Creating the safe space so they can talk about the trauma,” and “Finding creative and safe ways to do the trauma narrative.” The various components were referred to by 41(19.4 %) such as coping skills, relaxation, regulation and 25 (11.8 %) commented on children being distracted, noting that, “At times engagement can be an issue due to distractions. Therapist needs to be more creative in assuring successful strategies of engagement and limiting distractions via teletherapy.” Seventeen (8.1 %) said that the greatest difficulty involved doing art or play therapy, 15 (7.1 %) said that they experience challenges in reading emotional states, 14 (6.6 %) said that there were no challenges, 6 (2.8 %) mentioned challenges of privacy, 6 (2.8 %) mentioned difficulties in connecting with caregivers, 6 (2.8 %) mentioned a specific program, 5 (2.4 %) mentioned technology, and the remaining 17 (8 %) responses fell into the miscellaneous category including comments about needing to be more creative, not knowing which aspects were most challenging, and unspecified comments that “all” aspects were challenging.

Clinicians also shared what they thought was the hardest part for children when engaging in EBT via teletherapy. There were 207 valid responses. About one third (34.8 %) addressed the difficulties children have focusing and engaging; 34 (16.4 %) mentioned children’s difficulties with the trauma narration; 14 (6.7 %) said that there was nothing harder for the children, and 13 (6.3 %) mentioned lack of privacy as an issue. Topics raised by just a few clinicians included the physical distance (one comment was that, “Children miss the interactive element like being able to touch and share the same space”), emotion regulation, technology, screen fatigue, rapport, emotion regulation, play/art, a specific program, coping skills, homework, assessments, and relaxation. The remaining 18 (8.7 %) responses were miscellaneous and included attendance, feeling safe, recognizing the need for change, psychoeducation, and application.

3.4. Perceived impact of teletherapy on trauma narrations/imaginal exposure

Table 2 also presents the distribution of scores indicating impact of teletherapy on trauma narration/imaginal exposure (TN). As can be seen, around 18 % perceived no change on each aspect, about 30 % found most aspects to be both more and less challenging, while 45 % found these five aspects to be more challenging. Of note, about half said that it was more challenging to gauge the children’s emotions, 35 % each said that it was more challenging to know when the children are ready for the exposure and doing the components of the trauma narration. About one third said that it was more challenging to know when breaks are needed and to help children manage their emotions. These data were also examined separately for clinicians who did or did not have experience implementing a TN prior to the pandemic. An independent t-test was calculated for each of the five TN variables, two of which were statistically significant. Clinicians who had no prior experience with TN reported finding it less challenging to know when the child needs breaks (M = 2.5, SD = 0.94) than clinicians with prior TN experience (M = 2.79, SD = 1.1), t (227) = 1.93, p <.05. Similarly, clinicians without prior experience reported finding it was less challenging to help the child manage their emotions (M = 2.86, SD = 0.91) than clinicians with prior TN experience (M = 3.11, SD = 0.82), t (227) = 2.1, p <.04. The summary score reflecting the number (out of five) ways in which the trauma narration was perceived to be more challenging, revealed that 80 % of the sample reported that teletherapy created challenges in at least one way and 40 % reported that it created challenges in all five ways. The summary score for clinicians with no prior TN experience was statistically significantly lower (M = 2.7, SD = 2.1) than for clinicians with prior TN experience (M = 3.6, SD = 1.7), t (168), p <.002.

3.5. Perceived impact of technical and environment challenges on teletherapy

Table 3 presents the perceived impact of 12 possible challenges on service delivery of teletherapy. With respect to the number of issues perceived to be at least “somewhat” challenging only 4 % of the respondents reported none of the 12 to be somewhat of a problem while 30 % of the sample reported between 7 and 12 issues to be at least somewhat a problem. In general, clinicians had few concerns about their own devices, Wi-Fi, proficiency with software, privacy in their offices, quiet in their office, and interruptions. The mean number (out of six) which was perceived to be at least “somewhat” of a problem for the clinician was only 1.1 (SD = 1.7). However, approximately 90 % of the clinicians reported that at least some of their child clients had issues with their devices, Wi-Fi, privacy, quiet, and interruptions. The mean for the number of issues for the child was 4.8 (SD = 1.7). A paired t-test was conducted to determine whether the differences in reported challenges for clinicians and clients was statistically different. Results revealed a statistically significant difference, t(n = 249) = 27.6, p <.001, with clinicians reporting significantly more challenges for their clients than themselves.

Table 3.

Percentage Clinician Responses Regarding Impact of Technical Issues and Child Characteristics on Teletherapy.

	None	A little	Somewhat	Much	Very much
Technical Issues
Clinician device	63.8	17.5	06.9	04.1	07.7
Clinician Wi-Fi	44.7	24.4	24.6	08.5	07.7
Clinician software	62.7	18.0	10.7	03.7	04.9
Clinician privacy	68.7	17.1	05.3	06.1	02.8
Clinician quiet	63.3	21.0	07.3	04.8	03.6
Clinician interruptions	66.1	21.4	05.2	03.6	03.6
Child device	06.5	12.9	32.3	23.8	24.6
Child Wi-Fi	03.6	12.5	26.2	28.2	29.4
Child software	19.0	21.5	31.2	15.4	13.0
Child privacy	02.0	10.5	21.1	30.4	36.0
Child quiet	02.8	13.7	20.6	33.1	29.8
Child interruptions	03.6	11.3	27.0	29.4	28.6
Child Characteristics
Age	01.6	06.9	17.4	23.9	50.2
Gender	73.2	15.4	10.2	01.2	00.0
Attention span	00.8	02.4	12.7	25.3	58.8
Hearing/vision	08.3	06.7	26.7	22.9	35.4
On spectrum	02.5	05.9	22.6	30.1	38.9
Screen Fatigue	01.2	03.3	19.2	26.1	50.2

3.6. Perceived impact of child characteristics on teletherapy

As can be seen in Table 3, at least 75 % of the participants believed that age, attention span, being on the spectrum, and screen fatigue “very much” affected teletherapy. Slightly fewer perceived the child’s hearing and vision to impact effectiveness, and the vast majority believed that the child’s gender had little or no impact. With respect to the specific age perceived to be most challenging, 77.1 % said that it was up to six years, 16.3 % said that it was between 7 and 12 years, and 6.5 % reported that it was teenagers. The comments with respect to age almost exclusively mentioned the distractibility of younger children.

3.7. Training in teletherapy

As can be seen in Table 4 , many if not most of the clinicians did not receive training in each of the 10 areas. Fewest received training in dealing with hardware issues (28.6 %), dealing with software issues (29.3 %), and being aware of office triggers (34.8 %); and the most training was received in rapport with child clients (55.2 %), developing boundaries (49.6 %) and setting up a remote office (43.1 %). About one fourth (24.4 %) of the sample had training in none of the 10 topics and only half the sample had training in at least four topics. Only 10 % of the sample had training in all 10 topics. The average number of training topics received was 4.1 (SD = 3.5.).

Table 4.

Percentage of Clinician Responses Regarding Training Received and Wanted.

	Had training		Want training
	No	Yes	No	Yes	X2	Sig.
Collaborative documentation	59.9	40.1	42.5	57.5	1.7	NS
Dealing with hardware	71.4	28.6	60.1	39.9	0.3	NS
Dealing with software	70.7	29.3	55.4	44.6	2.6	0.05
Rapport with child clients	44.8	55.2	33.9	66.1	2.3	NS
Setting up remote office	56.9	43.1	46.7	53.3	3.7	0.04
Dealing with interruptions	62.4	37.6	40.0	60.0	0.74	NS
Developing boundaries	50.4	49.6	42.3	57.7	2.6	0.05
Aware of office triggers	65.2	34.8	35.6	64.4	11.9	0.001
Aware of home triggers	55.1	44.9	30.4	69.6	18.1	0.001
Observing interactions	52.2	47.8	22.3	77.7	7.1	0.001

With respect to wanting training, data reveal between 39.9 % and 77.7 % reported wanting training on each of the ten topics. Of particular interest was training in dealing with problematic behaviors observed in the home (77.7 %), being aware of home triggers (69.6 %), and developing rapport with clients (66.1 %). Lowest interest was in hardware issues (39.9 %) and software issues (44.6 %). The average number of training topics interested in was 5.9 (SD = 3.3).

Ten cross-tabulations were conducted and chi-squares were calculated to assess the relationship between having training on a topic (no/yes) and wanting training on that topic (no/yes). Those who had not yet had training in software issues were more likely to want training (47.7 %) than those who already had training (37.0 %), X ² (1, N = 249) = 2.6, p <.046. Those had not yet had training in setting up a home office were more likely to want training (58.6 %) than those who had already had training (46.2 %), X ² (1, N = 246) = 3.7, p <.036. Those who had not yet had training in dealing with boundaries were more likely to want training (62.4 %) than those who already had training (52.1 %), X ² (1, N = 248) = 2.6, p <.046. Those who had not yet had training in dealing with triggers for the child in seeing the clinician’s home office were more likely to want training (72.0 %) than those who already had training (50.0 %), X ² (1, N = 249) = 11.9, p <.001. Those who had not yet had training in dealing with triggers for the child having therapy in their home were more likely to want training (80.9 %) than those who already had training (55.9 %), X² (1, N = 247) = 18.1, p <.001. Those who had not yet had training in what to do when observing problematic behaviors in the child’s home were more likely to want training (84.5 %) than those who already had training (70.3 %), X² (1, N = 247) = 7.1, p <.007. In each case, those who had not yet had training reported wanting training. For the other variables, training was desired regardless of prior training received.

3.8. Child and clinician experience with COVID-19

Table 5 presents clinician and child client experience with COVID-19. As can be seen, the majority of clinicians were working with children who had someone important to them contract COVID-19, many of whom became seriously ill and/or died from the disease. Only 10 % of the clinicians contracted COVID-19, whereas two thirds had someone important to them contract it.

Table 5.

Percentage of Clinician Responses Regarding Clinician and Child Experience with COVID.

	N	%
Child contracted COVID	132	53.2
Someone important to child contracted COVID	189	76.5
Someone important to child seriously ill/died from COVID	82	33.1
Clinician contracted COVID	41	16.6
Someone important to clinician contracted COVID	170	68.8
Someone important to clinician seriously ill/died from COVID	75	30.2
Coworker contracted COVID	170	69.4

3.9. Secondary stress and care of clinician

Clinicians were asked two open-ended items. The first was how their secondary traumatic stress/ vicarious trauma has been affected by conducting teletherapy and the second was how COVID has affected their self-care. There were 206 responses to the first question, with 90 clinicians (43.7 %) stating that they did not feel an increase in secondary traumatic stress/vicarious trauma due to teletherapy, 14 (6.8 %) said that there was less stress, 81 (39.3 %) said that there was an increase in stress, and 21 (10.2 %) made comments about stress which did not indicate whether there was more or less. Of those who reported an increase in stress, comments focused on: (1) lack of boundaries between home and work, (2) burn-out, (3) zoom fatigue, (4) feeling helpless, (5) having to modify supervision to deal with increased stress, (6) needing to use more self-reflection, and (7) sadness about children missing important milestones.

Notable comments on this topic included, “I have experienced more vicarious trauma recently. Working remotely sometimes adds a feeling of 'Am I doing enough?’ There's a constant worry that something will be missed and it would be harmful for the client,” “I feel tired, burnt. I am overworked while trying to manage a global crisis that affects me and my clients in addition to previously experienced trauma,” “Unable to detach from work at the end of day and ‘leave it at the office’ typically doing work late into the evening and first thing in the morning now that my bedroom/bed is also my office/desk due to city apartment living,” and “There is no rest these days. The walls of my home are now absorbing the trauma that my office once did. There is no separation between healing for my patients.”.

Two hundred and nineteen clinicians responded to the item about how teletherapy has impacted their self-care. Of these, 28 (12.8 %) said that self-care did not change, 45 (20.5 %) said that self-care was actually easier, 137 (62.5 %) felt that self-care was harder, and 9 (4.1 %) were miscellaneous responses. For those who reported that self-care was harder, responses fell into three main categories. Sixty-one responses did not explain how it was harder, 40 said that lack of boundary between home and work made self-care harder, and 36 said that it was lack of access to opportunities for socialization and exercise.

Some of the comments included, “Being remote it is easy to be overly accessible to clients which makes it hard to recharge when I am off (weekends, vacations, etc.),” “I have difficulty practicing self-care. It can be difficult to make sure that I take breaks from work or working extra hours to try and get everything done,” and “I've done a terrible job taking care of myself.” A person who felt that self-care was improved noted, “Covid has allowed me to take a step back and take time to do things that I was interested in. In addition, the lack of the need to commute from home to work gave me my commute time back.”.

Stress was recoded into a dichotomous variable (not more secondary stress = 0, more secondary stress = 1) and self-care was recoded into a dichotomous variable (self-care not harder = 0, self-care harder = 1). A cross-tabulation was conducted and a chi-square was calculated which revealed that those who experienced more stress were more likely to find self-care harder (74.4 %) than those who did not feel more stress (53.1 %), chi-square (n = 1,176) = 8.4, p <.005).

4. Discussion

Two hundred and fifty mental health clinicians who provide teletherapy to children who have experienced trauma completed this on-line confidential survey. A number of important findings emerged from these data. First, the majority of clinicians perceived that providing mental health services via telehealth eased the process in at least some ways. They believed that providing therapy remotely reduced logistical barriers for families. Specifically, they reported that families had an easier time scheduling and attending sessions because there was no cost or time involved in traveling to the therapy office, nor did they have to address childcare needs of the other children in the family. These perceived benefits are consistent with pre-pandemic appreciation of remote services spurring the creation of professional organizational guidelines (e.g., American Psychological Association, 2013). Clearly, for families in which the time and financial costs associated with in-person treatment are prohibitive (i.e., rural families; families with limited means of transport; families that cannot accommodate the cost of transportation such as gas, tolls, and so forth), teletherapy should be maintained as an option. This is important because, despite tremendous need for evidence-based treatments for children who have experienced trauma, many symptomatic youths never receive treatment due to the kinds of barriers that teletherapy actually mitigates (Aisbett et al., 2007, Jones et al., 2014). It is important to note that lowering barriers to accessing services is only helpful if the services are effective in reducing symptoms and improving functioning.

With respect to perceived quality of treatment provided via teletherapy, the results were mixed with some aspects of care being viewed by clinicians as more challenging when provided via telehealth and some as less challenging, notably engaging with caregivers of child clients. Given that engagement of the parents is an important component of many evidence-based trauma-focused treatments provided to children (e.g., Brown et al., 2020, Brown et al., 2020, Haine-Schlagel and Walsh, 2015), this is a notable finding. From the comments provided by study participants, the reason for this is that caregivers can be invited into the session on an impromptu basis because they are in the home and accessible to the therapist.

At the same time, there were significant aspects of clinical care that were perceived by clinicians as more challenging when implemented remotely including developing rapport with the child clients, assessing the child’s feelings, and having the child feel emotionally supported. Specifically, the clinicians reported that the interpersonal aspects of mental health treatment such as reading emotional states and having shared emotional experiences, are sometimes harder because clinician and client are not in the same room. Some clinicians reported that it is harder to read the child’s emotional state because the clinician did not have access to the full set of emotional cues. The clinician usually cannot see the child’s full posture and body language from the remote camera especially if children are turned away from the camera or have the camera off. It is this ability to observe and share emotional experiences that plays a central role in the therapeutic process (Burum & Goldfried, 2007).

Consequently, the trauma narration was an area where many clinicians agreed, teletherapy made things more challenging, especially with respect to gauging the child’s emotions. The open-ended questions focusing specifically on the trauma narration revealed that clinicians felt that this was a particularly challenging aspect of teletherapy because the need for the child to feel supported is so high but the ability of the clinician to gauge the child’s emotional state and create a feeling of closeness is compromised because of the literal and figurative distance created by not sharing a physical space. Many clinicians felt that this aspect of the trauma work is not ideally suited for remote therapy. This is especially important in light of research showing that the trauma narration is associated with specific clinical benefits (Deblinger et al., 2011). It may make sense for hybrid models to be developed in which the trauma narration is conducted in person for clinicians who perceive it to be more challenging remotely, when possible or that additional thought and planning go into the implementation of this component when done remotely.

Interestingly, clinicians with prior TN experience actually found certain aspects of the trauma narrative more challenging than those with no prior experience. There are two possible explanations suggested by these data. The first is that, having no prior experience, they did not have a basis for comparison and did not know how much better and easier it could be. The second is that they did not have to unlearn certain ways of doing things that those who implemented the TN in person (prior to the pandemic) had already developed and acclimated to. Either way, the data suggest a need for training to support clinicians who both have had and have not had prior experience implementing the TN via telehealth.

With respect to providing evidence-based programs via teletherapy, a range of issues were raised by the clinicians with only two achieving any consensus: maintaining the child’s attention, focus, and engagement and – as noted above – implementing the trauma narration. Interestingly, no clinician mentioned that it was difficult to follow the manual per se or expressed concern that they were straying too far from the manualized program that they were implementing. In other words, the feedback was about what made teletherapy in general hard as opposed to what made evidence-based therapy per se hard. This may be because they felt that they were staying within the acceptable boundaries of the program manual or it may be because they simply were doing the best that they could and were not worried about this particular issue. It may be helpful for the issue of program fidelity to be looked at more closely. For example, clinical supervisors and/or program developers/evaluators could be monitoring fidelity specifically within the teletherapy context to determine if clinicians are able to administer the program as expected and if not, what aspects are the most difficult. Creative adaptations should be considered and tested, such as decreasing the duration and increasing the frequency of sessions (i.e., instead of one hour once weekly, sessions scheduled 30 min twice per week) to help with attention.

The second set of questions focused on the factors that impacted teletherapy. Technology-related aspects were perceived to be problematic more so for children than clinicians. Many of the technical issues are solvable and worth consideration by agencies that will continue to offer teletherapy in the future, either by choice or necessity. It is possible that public–private partnerships could be created to provide state-of-the-art devices and Wi-Fi service along with training and technical support so that families who would benefit from teletherapy can access it without technological barriers and struggles. Many foster care agencies purchased devices or received donations that were distributed to children and youth in care. While many agencies that provide mental health services to children and families may have information technology departments and help desks available to them, more resources to extend these services to child and family clients is worth considering moving forward.

Child age, attention span, and screen fatigue were all rated as very much a challenge for children; gender was not. Well over half of the clinicians rated all but gender as a child characteristic much or very much affecting the teletherapy experience. These data clearly show that there are some children who will be more easily served via teletherapy than other children. For example, a six-year-old child, diagnosed with ADHD, hearing issues, and in remote school learning is likely to have multiple challenges in teletherapy while a teenager who has no discernable attention, hearing, or vision issues and is not suffering from screen fatigue is likely to have an easier time. This suggests that when therapy must be remote, the clinician, client, and parent can anticipate certain challenges and work together to try to mitigate them. It also suggests that when teletherapy is an option, it is probably ideal for children without multiple risk factors. That being said, many clients of teletherapy may have these risk factors and it is suggested that training and supervision provide clinicians with additional tips, strategies, and resources for engaging children in the treatment process even when these risk factors are present.

The third area of focus for this study was on training. Here, a clear picture emerged. Most clinicians had not received training in a number of areas relevant to providing teletherapy to children who have experienced trauma, especially dealing with hardware and software issues, being aware of triggers for the child in seeing the clinician’s home/office, dealing with interruptions, and setting up a remote office. This is partly understood in light of the speedy process with which most clinicians transitioned from in-person treatment to remote treatment. There was literally no time for a carefully planned transition. However, given that a year has gone by, it is concerning that this training has not yet been provided. Not surprisingly, most clinicians reported wanting a range of training especially in what to do when they observe problematic aspects of the home environment, triggers specific to seeing the clinician’s therapy space, and triggers specific to the child having sessions in their own home. In fact, with one exception (dealing with software issues) more than 50 % of the clinicians expressed interest in additional training. Some practical solutions for these issues – such as encouraging clinicians to utilize virtual backgrounds – have been offered by Konigsberg, Lipscomb, et al. (2020). For some training topics, those who had not yet had training were more likely to want training (software, setting up a remote office, dealing with triggers in the child when the child sees the therapist’s home office, dealing with triggers in the child because the child is participating in therapy in his/her own home, and observing problematic parent–child interactions) while for other topics this was not the case. Perhaps, for some topics, the clinicians have already figured out how to deal with the issues, having been conducting teletherapy for over a year already. Regardless, the vast majority of clinicians wanted training on how to conduct teletherapy with children who have experienced trauma and clearly this is a need that agencies and training entities can and should address.

The final topic of the survey was on the specific experience of COVID-19 on the child and clinician. While most clinicians had not contracted the virus themselves, most were touched in some way either by having a child client, someone close to them, or a coworker contract it. This suggests that the providers of much-needed mental health services were likely to be more stressed and anxious themselves. The responses to the open-ended questions about stress and trauma revealed that about half of the clinicians, conducting trauma-informed therapy via a synchronous audiovisual platform did not experience an increase in secondary trauma reactions although a large minority (about 40 %) did report additional stress for a variety of reasons including lack of boundaries between the home and workplace and longer working hours each day. Those who reported more stress also reported finding it more challenging to engage in self-care. This is consistent with data from Miller et al. (2020) who found that in a survey of close to 2,000 child welfare workers, that about half were experiencing mild to severe distress because of the pandemic. They conclude with a call for the conceptualization, implementation, and evaluation of initiatives aimed at assuaging distress among child welfare workers. Many of the mental health providers surveyed in the current study confirmed that not only were they more stressed but their ability to engage in essential self-care was affected by the pandemic as well. Interestingly, about one fifth reported that they were less stressed when providing teletherapy and that is worth noting as many agencies may continue to offer this treatment modality and there may be a cadre of professionals who find this preferable.

When asked about their stress and coping during the pandemic, many commented that the hardest part was not having any separation between their home and their office, which created a lack of boundary in amount and timing of work as well as an inability to create a safe haven from the sadness and grief of their child clients. Self-care is imperative for the mental health provider and professional code of ethics emphasize its importance (Rupert & Dorociak, 2019). Without self-care, providers are at risk of burn-out as well as compromised services (Barnett et al., 2007). It is important that supervisors of clinicians providing teletherapy emphasize self-care and spend time in individual and groups supervision focusing on self-care and coping skills, especially making time for self-care and developing healthy boundaries between home and work. It is important to note that some of the stressors and barriers to self-care are only applicable for when a pandemic is occurring as opposed to on-going teletherapy offered during times when the clinicians are not simultaneously dealing with their own fears and concerns about a pandemic as well as restrictions in common self-care outlets. It is also notable that about four in ten clinicians reported that secondary stress was not a problem and about one third said that self-care was not harder. These are heartening statistics and point to the resiliency of these clinicians during extremely trying circumstances. Future research should aim to identify the individual, environmental, and structural factors that allowed these clinicians to avoid some of the worst outcomes of this experience.

5. Limitations

Limitations of the study include that the survey has face validity but not demonstrated construct validity. In addition, by the time the survey was conducted, most respondents had been providing teletherapy for a while (although we did not measure this). Therefore, the survey does not capture initial experiences with transitioning to teletherapy. It is likely that technology issues, feelings of inadequacy, and lack of training would be even more pronounced had we conducted the survey earlier in the pandemic. Additional limitations include that the survey only assessed the clinicians’ overall experience not on a case-by-case level where aspects of the individual child could also be included in the analysis, including the types of traumatic experiences the child was contending with. Moreover, the survey did not ask about all aspects of trauma-focused therapy. While it was not the goal to evaluate the effectiveness of the treatment provided, future research could focus specifically on the efficacy of telehealth, specifically for traumatized children.

6. Conclusions

Despite these limitations, the combined responses from the survey reveal that clinicians experience teletherapy as having unique and compelling advantages for clinicians and clients, especially with respect to scheduling, convenience, access, and utilization of services. Even though the pandemic may be winding down, as of this writing, it is likely that teletherapy will be around for some time and some clients and clinicians may actually prefer it to in-person sessions for a number of reasons.

For this treatment delivery mechanism to be maximally effective, however, it is clear that certain obstacles need to be addressed. One main area for improvement is upgrading clinician and client technical and practical tools. Clinicians reported that hardware and software issues were problems for them and for their child clients. This issue is primarily a function of funding and finances. We concur with Konigsberg, Lipscomb, et al.’s (2020) call for more resources, training, and support for both providers and clients of teletherapy. In addition, there may be a need to advocate for continued relaxation/modification of certain guidelines to allow for the continued practice. For example, insurance companies are currently reimbursing for teletherapy, and there may be a need for advocacy to ensure that this does not end, certainly not prematurely.

Second, there is a need for more systematic training on how to ensure that mental health treatment is maximally effective when delivered remotely. The vast majority of clinicians did not receive training on even the basics including how to set up a remote office or how to be aware of possible triggers when children can see the therapist’s home; and most wanted training in many of the topics asked about. It is clear that there are unique and specific aspects of providing teletherapy that the clinicians have not been sufficiently trained in and they are eager to learn how to do this work the best way they can.

Third, based on the data collected, it seems that therapists may perceive specific children to be differentially suited for teletherapy and there are specific aspects of the therapy itself that are better suited to telehealth and other areas that more training may be needed to adapt to a telehealth model. Therefore, we recommend that clinicians offering teletherapy to children consider a hybrid model based on clinical judgement and client preference in which both child and family characteristics and needs are taken into account and that – when feasible – certain stages of the therapy work be conducted in person (such as rapport building and the trauma narration) as opposed to remotely unless the therapists learn creative ways to adapt those stages of the model to teletherapy. We recommend that clinicians consider their own comfort level with conducting assessments, the initial sessions to develop rapport, and the trauma narration, and, if indicated, offer these sessions in person while other aspects of ongoing treatment be offered remotely when desirable for the client.

And finally, the need for more self-care was an important theme that emerged in the comments, primarily emanating from the lack of boundary between home and office. Many therapists mentioned feeling emotionally and physically fatigued while lacking sufficient means to replenish themselves. This will be partly eliminated if teletherapy is offered post COVID when clinicians can engage in recreational and social self-care activities that were not available to them during the pandemic. Nonetheless, clinicians may need more support and encouragement in their supervision around taking care of themselves not just their clients. Clearly, this is a topic that should be addressed in training as well as on-going clinical supervision for clinicians providing teletherapy. Both the children and the clinicians deserve nothing less. Given the likelihood of ongoing need for teletherapy with traumatized children, we recommend additional research in this area to build upon and extend the findings here. Additionally, fidelity studies should be conducted to systematically determine what aspects of evidence-based treatments need to be modified for remote modalities.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

The data that has been used is confidential.