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Tipsheet for clinicians working with youth during the COVID-19 pandemic: Ways to build rapport during telehealth sessions
Compiled by Ilana Seager van Dyk, Juliet Kroll, Ruben Martinez, Natacha Emerson & Brenda Bursch
UCLA Pediatric Psychology Consultation Liaison Service
Minimize any potential distractions in view of the camera in your workspace. Similarly, encourage caregivers to
minimize distractions in the room where the patient will be completing the session.
Young patients say they prefer a “less formal” room set-up, so you may wish to avoid having a table between the
patient and the video-recording device (or you and the video-recording device).
Many seating arrangements can work for children. Children can sit next to the caregiver, between the caregivers,
on a caregiver’s lap, or in front of the caregiver in either their own chair or on the floor.
Larger rooms tend to work best with younger patients, so they can move around. In addition, if a child's motor
skills, play, exploration, and movements are being assessed, the room should be large enough for this activity to
fit within the camera frame.
Teens may prefer to be seen without a caregiver present. Use clinical judgment to ensure appropriate privacy is
maintained (e.g., patient feels comfortable they are not being overheard). If a patient expresses any discomfort
with full video, text/chat functions are available in some telehealth systems and may be useful for older patients
(likely over 11 years old).
Ensure your video is sufficiently “zoomed in” for the patient to see your facial expressions.
Try to maintain a constant gaze into the camera, rather than frequently looking away at your computer or notes.
If you can, use picture in picture feature (e.g., where you can see both yourself and the patient) to see how you
are being viewed by the patient, or if there is something distracting in the background (e.g., your cat!).
Patients may enjoy using telehealth background features. This can support the patient’s sense of control, by
allowing the patient to choose the “location” for next session (e.g., in outer space or even upload a background
picture of a favorite location).
The following recommendations must be adapted to the developmental age of the patient:
Ask whether the patient has ever seen a doctor on a phone or computer. If the patient has not used telehealth, it
may be helpful to refer to common lay technology (i.e. Facetime, Skype, or Zoom) and explain key differences.
Let patients know why telehealth is being used. For example, mental health clinicians are using technology to
meet with patients during the COVID-19 outbreak so that everyone can stay as healthy as possible,” or “I am
using this so I don’t have to use a face mask to see you today.”
Communicate to patients that the session is happening in “real time,” if needed. You may demonstrate this by
commenting on the patient’s gestures, or what they are wearing, saying that “everything you can see about me, I
can see about you. For instance, you are wearing...” and “you just...” Children in particular seem to enjoy this
exercise and proof that they are being seen.
Discuss security, if needed. For example, teens might understand the concept of encrypted technology, which is
the HIPAA (Health Information Portability and Accountability Act) standard. If younger children express any
concerns about who else can hear or see them, it can be described as having an “electronic tunnel from the
camera where the clinician is sitting to the one where the patient is sitting.” Additional information regarding
technological specifications should be available if requested. Some patients appreciate being reassured that the
session is not “on the internet” in the sense that it can neither be openly viewed nor will it be placed online.
It is important to inform patients if a session is being recorded. If you want to record a session, then you must
obtain explicit consent from the patient. Teen patients who are recorded may appreciate information about what
recorded information may be shared with their parent (e.g. substance use, sexual activity, etc.). As appropriate,
provide information about mandatory disclosures. If sessions are being recorded solely for supervision purposes,
this may also be shared with the family so as to diffuse any worry about loss of privacy.
Establish a visual context of where you are sitting. Ask patients if they would like to see your office. Using the
camera’s zoom and pan features or manually moving your device, you can give patients a virtual tour of your
workspace to assure them that no one else is present and to provide context to the clinical setting. After the tour,
let the patient know that the camera will be zoomed in so that the patient can see your facial expressions.
Discuss any technical difficulties noticed immediately as they arise during the introduction. For instance, if there is
a slight lag in audio that makes it seem as if you and patient are talking over each other, you can suggest adding
a small pause after each statement. Socialize youth to the videoconferencing system, and highlight that it might
take time to acclimate to the technology and ‘‘not talk over each other.’’
Give patients an opportunity to ask questions before starting the session. This may be especially helpful to
younger and older patients who are not as comfortable with electronic media.
Provide opportunities for your patient to speak and/or assert control over the conversation given their inability to
"interrupt or speak over someone" with some telehealth formats.
If you are using or creating worksheets or other visual activities, consider allowing the patient to choose the
colors/fonts/pictures in order to provide them with some control.
Use exaggerated expressions and gestures if needed to engage the youth (virtual high 5s, thumbs up, etc.).
Use summary statements, reflections, and observations frequently to remind your patient that you are listening.
Seek more verbal confirmations of mutual understanding of what is being done in treatment (e.g., rationale for
relaxation, exposures, etc.).
Children may enjoy drawing pictures that they can then share through the camera while telling a story. These
drawings may help you assess children’s attention, fine motor skills and creativity. Children may also use play
figures (e.g., dolls, action figures) to demonstrate their ability for symbolic play and reveal their thought content.
For younger kids, ask them to share their favorite things about home toys, books, blankets, etc. insofar as
these can be related to clinical activities and are not disruptive. Encourage children to hold their drawings up to
the camera so they can explain them.
For older kids, ask if they have any art, journaling, music, or anything else to share with you. Consider engaging
adolescents by exploring an online site, such as YouTube or Facebook.
Children and teens may appreciate getting to know clinicians as well. Consider using a brief question and answer
game to share some facts about you and gathering information about your patient. For example, your patient and
you can take turns answering: What is your favorite TV show?”, “What is your favorite color?”, “What is your
favorite food?”, “How many siblings do you have?
Tentative language when interpreting patients’ statements, open-ended questions, and figurative language may
be helpful when conducting an initial session online.
Mirror the language patterns of the youth and handle any threats to rapport with genuineness (including using
informal language).
Simply have a conversation with the patient! This is shown to be a reliable rapport builder, even over telehealth.
Weather the inevitable technical and clinical challenges associated with telehealth with patience and humor.
Arts-based therapeutic methods may help engage younger patients. You can have the patient show you their
work on the camera or use screen share options to create art together (based on your platform’s capabilities).
Consider sharing handouts and working through them in session if your platform has the functionality (e.g., Zoom
screen share with editable documents or PowerPoints).
Try utilizing different functions to increase engagement (e.g., Zoom has a “whiteboard” feature where a patient
and clinician can draw together or play tic-tac-toe). Check with technology services at your site for specific
trainings and tips on functionality for your platform.
In sessions with younger children, make sure there are toys in the room where the patient is streaming from
but ask caregivers to avoid loud, noisy toys that will interfere with the audio quality. If needed, recruit caregivers to
help with engagement.
A hyperactive or autistic child may have difficulty remaining in the frame. Consider keeping the caregivers in
frame and call the child back to the camera when they need to answer a question.
If anxious or defiant youth refuse to sit within the camera frame, try to use typical behavior management
strategies first. Then, prior to the next session, ask the caregiver to turn off the self-monitor image and seat the
youth farther away from the camera so as to remain in the frame. Another strategy is to allow the youth to have
more privacy for part of all of the session.
Especially with younger patients, recognize that staying engaged via telehealth is challenging! Adjust your
expectations of how long sessions may last if you are having a hard time keeping your patient engaged.
Research shows that youth’s satisfaction with telehealth will likely increase with repeated use; youth who were
initially anxious about telehealth showed decreased distress in about 10-15 minutes.
It is important to continue conversations related to technical difficulties, unique challenges, or positives that come
from using telehealth throughout the treatment course. Keep asking!
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Psychiatric Association. Retrieved March 17, 2020, from
Roth, D. (n.d.). Child & Adolescent Telepsychiatry: Participant Arrangement. American Psychiatric Association. Retrieved
March 17, 2020, from
Timm, M. (2011). Crisis counselling online: Building rapport with suicidal youth.
Full-text available
Este artículo describe la adaptación de un tratamiento cognitivo-conductual en línea para la depresión en una niña de siete años. Destaca los retos que supone adaptar una intervención basada en evidencia probada en la práctica clínica de forma presencial, para su aplicación en internet. Se presenta un estudio de caso que ilustra los aspectos prácticos y técnicos de la implementación de la intervención, y demuestra la viabilidad de lograr resultados exitosos brindando la atención mediante esta vía. Se evaluó e implementó el tratamiento al inicio del aislamiento social debido a la pandemia del COVID-19. El programa ayudó a disminuir la sintomatología depresiva, así como sus comorbilidades (ansiedad, déficit de atención y problemas de conducta), además de mejorar en dos de las tres metas de tratamiento planteadas. Sin embargo, no se pueden obtener conclusiones firmes sobre la eficacia del tratamiento hasta que se disponga de diseños metodológicos más rigurosos. El estudio identifica direcciones para investigaciones futuras.
Full-text available
Objective: The purpose of this study was to describe the special considerations for building rapport and establishing a therapeutic alliance when conducting mental health evaluations for children and adolescents via videoconferencing. Methods: The authors review the literature and describe their experience in conducting mental health evaluations, developing rapport, and establishing a therapeutic alliance during telemental health practice. Results: Clinical need and shortages of clinicians with expertise in evaluating mental conditions for children and adolescents in underserved communities have stimulated the rapid expansion of telemental health programs while the research base continues to develop. The emerging evidence base and clinical experience suggest that teleclinicians can, and do, build rapport and establish a therapeutic alliance during telemental health sessions with youth and families. Families may be more accepting of telemental health approaches than clinicians. The impact that technology, equipment, site staff, community supports, cultural identification, and teleclinicians' characteristics have on building rapport and establishing a therapeutic alliance should be considered when establishing a telemental health service. Staff at the patient site and referring providers have a valuable role in supporting the therapeutic alliance between telemental health providers and their patients, and ultimately supporting the success of a telemental health program. Conclusions: Teleclinicians are creative in transcending the videoconferencing technology to evaluate patients using guideline-based care. Further research is needed to determine how clinicians build rapport and establish a therapeutic alliance during telemental health sessions, and whether the therapeutic alliance is associated with the accuracy of evaluation and outcomes.
Full-text available
It is critical to consult young people about their experiences. This study addresses the paucity of research on the perspective of young people in general, and in paediatric telepsychiatry specifically. The goal is to understand the experience of young people receiving telepsychiatry. Interpretive interactionism (Denzin, 1989) was used to interview 30 young people; immediately following the consultation and four to six weeks later. Analysis occurred via a series of steps in keeping with the interpretive interactionist framework. Four themes arose repeatedly: the encounter with the psychiatrist and experience of having others in the room; the helpfulness of the session; a sense of personal choice during the consultation; and, the technology. Participants highlighted the importance of their relationship with the psychiatrist. Participant's narratives were replete with examples of ways that they actively took responsibility and exerted control within the session itself. Young people have a significant role to play in their own care. It is critical that telepsychiatry recommendations be explained and opportunities for young people to express their concerns and discuss alternatives are provided. Further efforts to include young people may include ensuring offering alternate treatments and/or negotiated when recommended treatments are unacceptable and/or resisted.
Background: Because of the widening access gap between need for individual and pediatric psychology services and child specialist availability, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. Methods: The authors summarize real-time videoconferencing evidence to date across individual therapy with children and pediatric psychology interventions using videoconferencing. The authors summarize emerging guidelines that inform best practices for individual child therapy over videoconferencing. Results: The authors present three case examples to illustrate best practices. The first behavioral pediatrics case summarizes evidence-based approaches in treating a rural young adolescent with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and hearing impairment. The second pediatric psychology case describes similarities and difference between on-site and videoconferencing services in treating a rural child with toileting concerns. The third adolescent case describes treatment of an urban honors student with depression. Conclusions: Videoconferencing is an effective approach to improving access to individual and pediatric psychology interventions for children and adolescents. Videoconferencing approaches are well accepted by families and show promise for disseminating evidence-based treatments to underserved communities.
Most children and adolescents across the USA fail to receive adequate mental health services, especially in rural or underserved communities. The supply of child and adolescent psychiatrists is insufficient for the number of children in need of services and is not anticipated to grow. This calls for novel approaches to mental health care. Telemental health (TMH) offers one approach to increase access. TMH programmes serving young people are developing rapidly and available studies demonstrate that these services are feasible, acceptable, sustainable and likely as effective as in-person services. TMH services are utilized in clinical settings to provide direct care and consultation to primary care providers (PCPs), as well as in non-traditional settings, such as schools, correctional facilities and the home. Delivery of services to young people through TMH requires several adjustments to practice with adults regarding the model of care, cultural values, participating adults, rapport-building, pharmacotherapy and psychotherapy. Additional infrastructure accommodations at the patient site include space and staffing to conduct developmentally appropriate evaluations and treatment planning with parents, other providers, and community services. For TMH to optimally impact young people's access to mental health care, collaborative models of care are needed to support PCPs as frontline mental health-care providers, thereby effectively expanding the child and adolescent mental health workforce.
Concepts of rapport and therapeutic alliance have been found to be robust predictors of treatment response and can be impacted by technology found in telemental health. This chapter reviews the relevant research on rapport and the concepts of therapeutic alliance as they impact telemental health and discusses practical considerations impacting technology choices, such as technology that allows sufficient bandwidth for fluid transmissions and detailed observations of patients. Careful consideration of rapport within the context of individual interactions, relationships with local clinicians, and communities at large are also discussed. The focus is on a practical understanding of rapport with concrete recommendations to develop relationships within the telemental health setting.
Access to psychiatric care for children and adolescents is limited outside of urban areas. Telepsychiatry provides one mechanism to bring needed services to youth. This investigation examines whether telepsychiatry could be successful in providing needed services. Using interactive video teleconferencing at 384 kilobits per second, psychiatrists based at a regional childrens hospital provided consultation and management services to patients at 4 sites across Washington State located 75150 miles from the childrens hospital. Twelve-month review of billing records provided utilization data. Surveys of parents satisfaction over 12 months examined whether parents would accept and be satisfied with the care rendered to their children. Over the study year, 387 telepsychiatry visits were provided to 172 youth 221 years old with a mean of 2.25 visits per patient. The demographic and diagnostic profile of this sample was consistent with usual outpatient mental health samples. Parents endorsed high satisfaction with their childrens telepsychiatric care, with an indication of increasing satisfaction upon return appointments. Parents demonstrated some differential satisfaction, tending to higher satisfaction with their school-aged childrens care and lower satisfaction with their adolescents care. Telepsychiatry offered through a regional childrens hospital was well utilized and parents were highly satisfied with their childrens care. The stage is now set for integrating telepsychiatry into a system of care that meets youths overall needs and for controlled studies demonstrating the efficacy of telepsychiatry with youth.
Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space
  • C Rockhill
  • F Goldstein
Rockhill, C., & Goldstein, F. (n.d.). Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space. American Psychiatric Association. Retrieved March 17, 2020, from
Child & Adolescent Telepsychiatry: Participant Arrangement
  • D Roth
Roth, D. (n.d.). Child & Adolescent Telepsychiatry: Participant Arrangement. American Psychiatric Association. Retrieved March 17, 2020, from