Considerations for psychologists working with children and young people using online video platforms during Covid 19
DCP Faculty for Children, Young People and their Families in association with the Digital Healthcare Sub-Committee. There has been increasing interest in the potential contribution of using video platforms for clinical work, particularly with teenagers and the current pandemic has accelerated the implementation of this means of communication. This will be a new way of working for many clinicians and this guidance is written to help people to think through and prepare their practice so that it becomes a positive development in services. We have written this guidance for psychologists, but we hope it will be useful for other psychological practitioners. The guidance should complement local guidance and help psychologists think about some of the unique issues that arise when working with children and young people of different ages and developmental stages using online video methods. Other forms of remote working (telephone, text, email, online chat) are not specifically considered here, but they may be preferable or necessary (e.g. if there is limited broadband or connection issues). We are very clear that one size will not fit all, and you will need to adjust this guidance for the specific needs of your individual clients. This should be read alongside the BPS resource paper ‘Effective therapy via video: top tips’. Work with children and young people generally takes place in the context of work with parents and carers; this means that the needs of parents/ carers and children will need to be balanced and the responsibilities and needs of parents/carers also appropriately addressed.
1. Specific Issues For Working With Children And Young People Via Video
There are developmental considerations which mean that working via video may fundamentally change the nature of the work.
• Ensure that the child/young person is able to give consent to work via video.
• For younger children: use professional judgement about whether the child is able to engage with video sessions. Some children/young people may not want to engage with video therapy.
• Give repeated choice in all sessions for the child to continue with therapy online or to wait until social distancing is lifted even though this is currently uncertain. Advocate on behalf of the child/young person with parent/carers if video sessions might not work for them.
• Check in repeatedly with the child/young person to make sure that they understand the process of working by video, are able to engage with it in a meaningful way, and that they feel safe and contained when working by video.
Have a set format for sessions so everyone knows what to expect:
For younger children: this should include checking in with parents/carers at the start of every session in order to understand any changes in the child or family situation and to reinforce expectations on both sides; this may include checking in with parents at the end of sessions if this is appropriate to the work.
• For older teenagers: there may not be a need to check in with parents.
• Consider whether you can still work on the issues you were previously working on, and renegotiate therapeutic goals especially when working with younger children or, in the current fast moving circumstances, when something significant for the child has changed.
• Consider how you will work creatively when you cannot interact with the child through play or drawing; consider how you will minimise the requirement for increased reliance on spoken language especially for younger children. How will younger children express themselves in sessions? If you want to use screen sharing ensure that you are both familiar with how it works.
Consider how you will manage confidentiality:
• Children of any age may not feel safe in their own homes, and some may fear that an adult is listening in.
• Ensure you have set clear expectations for who can be in the room during the session, and consider how you will know who is in the room.
Ensure you convene the sessions on a private video link.
Consider how you will create safety and containment for the child.
• Younger children may not feel comfortable talking online or via video and may need reassurance about the safety of their information and about seeing themselves on screen (which may also be distracting).
• Does the child understand that you are not present, even though they can see you?
• Seek regular feedback from children during sessions so that you can gauge whether they feel comfortable with working this way.
• Give careful consideration to the issues you are going to work on with video.
• Ensure that you have breaks in the session for younger children if needed, or shorter sessions.
Consider how you will deal with a child who becomes distressed (see section 2 below).
• Consider whether working with a family group is appropriate via video.
• Seek feedback from the child/young person about how they find the sessions, and change things as needed.
2 . Contracting For Video Sessions
.If there is no confidential space within the home then consider how you will adapt the psychological work.
• Be aware that siblings or other family members may unpredictably appear in the sessions.
• Have an agreement about what will happen if the child/young person becomes distressed or has to end the session, or if there are technical difficulties.
• For younger children: This should include an alternative telephone number to contact the parent/carer.
• For teenagers: this should be negotiated and the psychologist should make an informed professional judgement as to whether this is needed.
• An understanding that the psychologist convenes the sessions, invites the child/young person to attend at a specified time through a unique link that is shared only with the parent/young person, and that video contact between sessions is not appropriate.
• For younger children: video contact should take place through a parent/carer video account for younger children.
• For teenagers: using a teenager’s account may be preferable, but this should be using professional judgement.
• There may be increased demands on children’s attention, and they may be coping with distractions that are unseen by the psychologist.
• Be clear with children and parents/carers that any safeguarding concerns will be managed in the usual way; be mindful that video may reveal risks that might have been unknown before, including poor living conditions, behaviour of other family members etc.
Have a clear written contract for video sessions that includes:
• What the basic requirement for sessions are (e.g. nobody else should be in the room unless this is agreed in advance.
• For younger children: sessions should not take place in the child’s bedroom but in a space in the home that can be made confidential.
• For teenagers: a bedroom may be appropriate but this should be by explicit agreement; discuss with young people that other screens should not be in use during the session. For older teenagers: it may also be appropriate for sessions to take place outside of the family home, for example whilst out taking permitted exercise.
• Contracts for video work need to ensure that there is an agreement that children/young people or parents/carers must not record any part of the session, but be aware that you will only have their undertaking that recording is not taking place).
3.What Psychologists Need To Ensure They Have Done
If working from home ensure that you have the required level of confidentiality in your own home – if not, then do not conduct video sessions.
• Ensure confidentiality; if the child’s living conditions do not allow for confidentiality of sessions then the sessions may need to wait until this can be achieved, or until face to face sessions are able to resume. In this situation there may need to be other forms of support offered, or a renegotiation of therapeutic goals to provide general family support.
• Consider the child’s developmental requirements in all aspects of the process, and make an informed judgement about whether video sessions are right for this child/young person.
• Make sure to explicitly consider any additional needs the child may have, including neuro developmental differences, sensory processing difficulties, learning difficulties etc.
• Ensure that there is an initial discussion with a parent/carer to find out if there are new issues for the child or family related to Covid-19; these might include family illness, increased anxiety, etc. This will also ensure that there is a parent/carer in the house during the session.
• If there are new issues (e.g. new experiences of heightened anxiety) then these may need to be the focus of the video session in order to create safety and containment this should be done at the start of every session due to the fast changing nature of the current situation.
• Ensure that supervision and team structures remain in place so that supervision in relation to remote working can be developed.
• Ensure that the video platform is used with a password (so that only the psychologist and child/ parent can be in the meeting) and appropriate security is enabled.
• Ensure you have checked that your employer and professional insurer are happy to cover video working and that you are GDPR compliant. Be aware of NHSx guidance on information governance during Covid-19
4 . Conducting Psychological Assessment By Video
Any standardised assessment will be unlikely to remain standardised when delivered by video, unless it is designed to be delivered this way. Refer to test publishers’ guidance (available on their websites). You should also be aware that if sessions are recorded without your knowledge this may compromise the validity of the assessment tool.
• Assessments that can wait, should wait; any that cannot should be reported with extreme caution.
• For assessments that cannot wait (including where there is family court involvement) ensure that relevant guidance is followed, and, as above, interpret assessments with extreme caution.
5 . Keeping Engagement When You Con't Work By Video
• The prospect of video therapy might be experienced as intrusive or uncomfortable to many, so an initial session by telephone may be required to encourage early engagement.
• Consider whether working by telephone, WhatsApp or text may be more suited for some families.
• For families where video working is not possible or not desirable, then make a plan for how you will keep in touch with children/young people and parents/carers. Be aware that video may not work for some children/young people.
surge to solution
Recovery and long term
Planning may happen at a high level in a rapid time frame leading to anticipatory anxiety
about the unknown.
With limited time to plan, and limited input into the preparation phase, many staff may not report feeling ‘prepared’ for the outbreak.
Many UK Health Trusts have now passed through this phase.
Increased camaraderie as staff cross boundaries and work together.
Sense of rising to a challenge.
Staff may respond on instinct and are more prone to error. They may lack the head space to see all options.
Frustrations and role confusion as people try to adapt quickly within current system design.
Staff witnessing things they have never seen before and feeling out of control.
Disagreement between groups over sense of urgency.
Staff lose usual boundaries over working hours and breaks and
start to over-work.
Work-life tensions arise as family life also becomes unsettled.
Social norms and niceties slip and behavioural responses
may causes difficulties
Focus on ‘getting things done’ which may lead to poor communication and silo working.
The period of highest psychological risk.
Staff are in ‘full go mode’ with high levels of adrenaline and on
‘automatic pilot’. They may then experience sudden exhaustion.
They may neglect physical and
psychological self- care as they feel it is not a priority.
Moral distress and injury are a risk as healthcare becomes
limited and people are unable to act or respond within their own moral or ethical code and
death and dying may not be handled in the way it usually is (with family etc.).
Staff may begin to feel
emotionally disconnected from the work, experience compassion fatigue, and may engage in avoidant or unhelpful coping.
Tensions at home and within the wider family may over-run work life.
Stress has a cumulative effect and smaller things trigger reactions.
Staff with pre-existing vulnerabilities are at higher risker of crisis and suicidality.
Staff have time to start to reflect.
Most staff will feel able to cope successfully using their own
preferred style, individual resources and social support.
Many may be changed in a positive way, experiencing personal development, and post traumatic growth.
Some may experience intrusive thinking about what they ‘should’ have done differently
and shame or guilt. Dissonance with a ‘heroes’ narrative may
make this harder to disclose problems and may exacerbate distress.
Others may feel differently about their job and experience
resentment towards individuals and towards the organisation.
Individual difficulties have wider family and social impacts which may further exacerbate these longer- term impacts.
Certain staff may be at risk of chronic psychological difficulties
(including but not limited to burnout and post-traumatic stress).