Working From Home: An Initial Pilot Examination of Videoconferencing-Based Cognitive Behavioral Therapy for Anxious Youth Delivered to the Home Setting

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

A Comparison of Telehealth and In-Person Therapy for Youth Anxiety Disorders

OBJECTIVE

At the onset of the COVID-19 pandemic, telehealth service use increased. However, little research has compared the efficacy of individual cognitive behavioral therapy (CBT) for youth with anxiety administered via (a) telehealth and (b) in-person. The present study used non-inferiority analyses to examine outcomes for youth with anxiety disorders (diagnosed by an Independent Evaluator; IE) treated via telehealth during the COVID-19 pandemic and youth treated via in-person therapy prior to the COVID-19 pandemic.

METHOD

Participants (n = 92; Mage = 11.5 years; 60.1% female; 75.0% White) were 46 youth who completed telehealth treatment and 46 youth who completed services in-person, matched on age and principal anxiety diagnosis. One-sided t-tests for non-inferiority were first estimated. Next, ANOVAs and regression models were performed, examining treatment differences and candidate moderators (e.g. social anxiety disorder, comorbid attention problems).

RESULTS

Results support non-inferiority across multiple indices of outcomes (i.e. self- and caregiver-reported anxiety symptoms, IE-rated functional impairment, and IE-rated treatment response). Analyses indicate that both treatments were effective in reducing anxiety symptoms and functional impairment. Caregivers reported higher post-treatment levels of anxiety for youth treated via telehealth than youth treated in person. No variables moderated the differences in outcomes between treatment modalities.

CONCLUSIONS

Findings support that CBT administered via telehealth is similarly efficacious as CBT administered in-person for youth with anxiety. Implications regarding the availability and accessibility of evidence-based treatment for youth with anxiety are discussed.

Internet-Based Versus Face-to-Face Cognitive-Behavioral Therapy for Social Anxiety Disorder: A Randomized Control Trial

During the COVID-19 epidemic, face-to-face mental health services faced obstacles. Using Internet-based interventions was a good solution and had the potential to overcome these treatment barriers. However, there is no strong research evidence about the effectiveness of these methods for social anxiety disorder in different cultures and developing countries. Therefore, the present study aimed to investigate the effectiveness and application of Internet-based cognitive-behavioral therapy for social anxiety disorder in Iran. The current study was a pretest-posttest follow-up experimental design. Fifty-four adolescents with social anxiety disorder were selected from Lorestan province (Iran) by cluster sampling method and randomly assigned to three groups: face-to-face, internet-based, and wait-list control. At the beginning and end of the study and 3-month follow-up, three groups were interviewed and answered questionnaires related to the primary and secondary symptoms of social anxiety disorder. Two experimental groups were treated with the same therapeutic intervention during 10 weekly sessions. ANCOVA analysis showed that both forms of intervention effectively reduced social phobia, fear of negative evaluation and social interaction anxiety and increased emotion regulation. Also, a significant decrease in secondary outcomes, including physical symptoms, insomnia, social dysfunction, and depression symptoms, was observed in both groups. The treatment effects were stable during a 3-month follow-up. Our findings showed that although Internet-based cognitive-behavioral therapy for adolescents with social anxiety disorder can be effective, several clinical, cultural, and implementation weaknesses should be considered.

Enhancing Pediatric Mental Health Care in an Outpatient Primary Care Setting Using the Keep Your Children/Yourself Safe and Secure (KySS) Program: A Multidisciplinary Quality Improvement Project

INTRODUCTION

This project aimed to enhance access to pediatric mental primary health care.

METHOD

The Keep Your Children/Yourself Safe and Secure (KySS) training was offered to a multidisciplinary team at a Federally Qualified Health Clinic in the Midwest United States. Confidence was measured using the Healthcare Provider Confidence Scale (HPCS). Frequencies of visits and mental health referrals were compared preintervention/postintervention. HPCS scores were compared using Wilcoxon rank-sum and Cohen's d.

RESULTS

Referrals in 2022 were greater than in 2020 but less than in 2021 (p = .25). The total number of visits declined from 431 in 2021 to 385 in 2022. HPCS (n = 9) scores trended higher following the KySS Program in prescribing and general positive beliefs.

DISCUSSION

Referrals to mental health providers increased, although not significantly. The number of mental health visits varied between 2020-2022. Provider confidence was not significantly affected, whereas beliefs in prescribing did increase significantly. More work is necessary to understand the impact of delivery to a multidisciplinary team.

Physiotherapy via telehealth for acute respiratory exacerbations in paediatric cystic fibrosis

INTRODUCTION

The demand for Hospital in the Home has increased, especially as an avenue for treatment of respiratory exacerbations. However, a limiting factor of Hospital in the Home efficiency is excess travel. Telehealth can potentially increase in-home access to specialist care such as physiotherapy. This study examined clinical outcomes achieved with a hybrid telehealth model and assessed safety and efficiency.

METHOD

This study was an observational benchmarking study of Hospital in the Home physiotherapy episodes of care during respiratory exacerbations between January 2017-June 2019. The participants were young people aged 8-18 years, with cystic fibrosis receiving intravenous antibiotics and bi-daily physiotherapy. The intervention was physiotherapy via either a hybrid model (1× telehealth, 1× face-to-face session) or standard care (2× face-to-face sessions). The outcomes were frequency of return to at least 95% of baseline percentage predicted forced expiratory volume in the first second (ppFEV1), ppFEV1 change, adverse events, travel time and distance saved.

RESULTS

There were 82 episodes of Hospital in the Home; 41 hybrid and 41 standard care. Return to at least 95% of baseline was achieved in 49% of the hybrid group and 32% of standard care. Median ppFEV1 change was +6% for the hybrid group and +2% standard care. There were no adverse events. Estimated travel time and distance saved was 16,520 min and 12,301.2 km.

CONCLUSION

Preliminary information supports a hybrid telehealth physiotherapy model as an alternative to standard care for young people with cystic fibrosis during an exacerbation. Safety of telehealth in conjunction with home visits favoured its use to improve efficiency and capacity without added risk.

FIT Teens RCT for juvenile fibromyalgia: Protocol adaptations in response to the COVID 19 pandemic

Objective

To describe protocol adaptations to the Fibromyalgia Integrative Training for Teens (FIT Teens) randomized controlled trial in response to the COVID-19 pandemic. The overarching aims of the FIT Teens multi-site 3-arm comparative effectiveness trial are to assess whether a specialized neuromuscular exercise training intervention combined with cognitive-behavioral therapy (CBT) is superior to CBT alone or graded aerobic exercise alone.

Design/methods

The trial was originally designed as an in-person, group-based treatment with assessments at baseline, mid- and post-treatment, and four follow-up time points. The original study design and methodology was maintained with specific modifications to screening, consenting, assessments, and group-based treatments to be delivered in remote (telehealth) format in response to COVID-19 restrictions.

Results

Study enrollment was paused in March 2020 for five months to revise operations manuals, pilot remote treatment sessions for accuracy and fidelity, complete programming of REDCap assent/consent and assessment materials, train study staff for new procedures and obtain regulatory approvals. The trial was relaunched and has been successfully implemented in remote format since July 2020. Trial metrics thus far demonstrate a consistent rate of enrollment, strong attendance at remote treatment sessions, high retention rates and high treatment fidelity after protocol adaptations were implemented.

Conclusions

Preliminary findings indicate that FIT Teens protocol adaptations from in-person to remote are feasible and allowed for sustained enrollment, retention, and treatment fidelity comparable to the in-person format. Methodologic and statistical considerations resulting from the adaptations are discussed as well as implications for interpretation of results upon completion of the trial.

Attitudes of children, adolescents, and their parents toward digital health interventions: a scoping review (Preprint)

BACKGROUND

The prevalence of mental health problems in children and adolescents is high. As these problems can impact this population's developmental trajectories, they constitute a public health concern. This situation is accentuated by the fact that children and adolescents infrequently seek help. Digital health interventions (DHIs) offer an opportunity to bridge the treatment gap between health care needs and patient engagement in care. Additional detailed research is needed to identify how children and adolescents can be empowered to access help through DHIs. In this context, an understanding of their attitudes toward digital health appears to be a necessary first step in facilitating the effective implementation of DHIs.

OBJECTIVE

This study aimed to establish an inventory of children's, adolescents', and their parents' attitudes toward DHIs.

METHODS

A scoping review following PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) recommendations was performed using the MEDLINE, Embase, and PsycINFO databases. This research was conducted using 3 key concepts: "child and adolescent mental health service users," "digital health interventions," and "attitudes." Data extracted included the name of the publishing journal, the methodology used, the target population, the DHI studied, and the principal results.

RESULTS

Of 1548 studies found, 30 (1.94%) were included in our analysis. Among these, 13 concerned satisfaction, 24 concerned preferences, 22 concerned the use of DHI, 11 concerned perception, and 10 concerned needs.

CONCLUSIONS

The results of this study provide a better understanding of the factors influencing children's and adolescents' attitudes toward digital health and DHIs. The continued growth of DHIs can help reduce barriers to mental health care. Future research on these interventions should investigate the needs of the targeted populations to increase their engagement in care.

Examination of Telemental Health Practices in Caregivers of Children and Adolescents with Mental Illnesses: A Systematic Review

In this systematic review, effects of telemental health (TMH) practices' on caregivers of children/adolescents with mental illnesses were investigated. The literature review included databases, and reference lists of published studies. All studies published until September 2021 were reviewed. Eleven studies were included. Several services were provided via TMH: education, cognitive behavioral therapy (CBT), parent training, caregiver behavior training, family CBT. The effectiveness of TMH interventions on caregivers varied from low to high. Most reproducible findings were on caregivers' satisfaction, stress, therapeutic alliance and caregiver burden. Studies had a low to high bias risk. Most studies had small samples. Results built on the small but growing literature support TMH interventions' promising role in caregivers of children with mental illness. Future studies should estimate outcomes with medium to low effect size. Other caregiver groups, rarely considered in previous studies, should be included. Bias risk should be minimized. Larger, more methodologically rigorous studies should be conducted.

The effective delivery of digital CBT: a service evaluation exploring the outcomes of young people who completed video conferencing therapy in 2020

Despite its impressive evidence base, there is a widening access gap to receiving cognitive behavioural therapy (CBT). Video conferencing therapy (VCT) offers an effective solution for logistical barriers to treatment, which has been salient throughout the Coronavirus pandemic. However, research concerning the delivery of CBT via VCT for children and young people (CYP) is in its infancy, and clinical outcome data are limited. The aim of this service evaluation was to explore the effectiveness of a VCT CBT intervention for CYP referred from Child and Adolescent Mental Health Services (CAMHS) in the UK. A total of 989 records of CYP who had completed CBT via VCT in 2020 with Healios, a digital mental health company commissioned by the National Health Service (NHS), were examined to determine changes in anxiety, depression and progress towards personalised goals. Routine outcome measures (ROMs) were completed at baseline and endpoint, as well as session by session. Feedback was collected from CYP and their families at the end of treatment. There was a significant reduction in symptoms of anxiety and depression and significant progress towards goals, with pre- to post-effect sizes (Cohen’s d) demonstrating medium to large effects (d=.45 to d=−1.39). Reliable improvement ranged from 31 to 80%, clinical improvement ranged from 33 to 50%, and 25% clinically and reliably improved on at least one measure; 92% reported that they would recommend Healios. This service evaluation demonstrates that Healios’ CBT delivered via VCT is effective for CYP receiving it as part of routine mental health care.

Key learning aims

(1)

Remote Intensive Group Behavioral Treatment for Families of Children with Selective Mutism

Selective mutism (SM) is a relatively rare, but highly interfering, child anxiety disorder characterized by a consistent failure to speak in certain situations, despite demonstrating fluent speech in other contexts. Exposure-based cognitive behavioral therapy and Parent-Child Interaction Therapy adapted for SM can be effective, but the broad availability and accessibility of such specialty care options remains limited. Stay-at-home guidelines to mitigate the spread of COVID-19 further limited the accessibility of office-based specialty care for SM. Building on separate lines of research supporting intensive treatments and telehealth service delivery models, this paper is the first to describe the development, preliminary feasibility, acceptability, and efficacy of a Remote Intensive Group Behavioral Treatment (IGBT) for families of young children with SM (N=9). Treatment leveraged videoconferencing technology to deliver caregiver training sessions, lead-in sessions, 5 consecutive daily IGBT sessions, and an individualized caregiver coaching session. Remote IGBT was found to be both feasible and acceptable. All families (100%) completed diagnostic assessments and caregiver-report questionnaires at four major study timepoints (i.e., intake, pre-treatment, post-treatment, 4-month follow-up) and participated in all treatment components. Caregivers reported high treatment satisfaction at post-treatment and 4-month follow-up and low levels of burden associated with treatment participation at post-treatment. Approximately half of participating children were classified as treatment responders by independent evaluators at post-treatment and 4-month follow-up. Although these pilot results should be interpreted with caution, the present work underscores the potential utility of using videoconferencing to remotely deliver IGBT to families in their natural environments.

Describing Changes in Telebehavioral Health Utilization and Services Delivery in Rural School Settings in Pre- and Early Stages of the COVID-19 Public Health Emergency

BACKGROUND

Receiving treatment for behavioral health disorders remains problematic due to profound provider shortages. Telebehavioral health services are effective for providing quality care, but research literature on these services in schools is limited.

METHODS

Data were collected during Fall 2019 and Spring 2020 semesters on all students receiving telebehavioral health services from 15 school-based telehealth programs across the U.S.

RESULTS

From Fall 2019 to Spring 2020, 62 schools providing services during both periods increased the number of students served from 396 to 745, increased the average number of encounters per student from 2.4 to 4.1, increased the percentage of encounters delivered by clinical social workers, mental health counselors, and clinical psychologists (all p < .001), and increased the use of individual counseling, family counseling, and group counseling (all p < .001). Schools that initiated the service in Spring 2020 (n = 25) averaged 6.5 encounters for the 301 students receiving services, delivered mostly by clinical social workers or professional counselors, using individual counseling.

CONCLUSION

Overall, data indicate programs significantly increased both behavioral services provided to their ongoing schools and increased the number of schools served. Undoubtedly telebehavioral health care delivery provided a swift and necessary response to the challenges posed by the growing pandemic threat.

Therapeutic Alliance in Cognitive Behavioural Therapy in Child and Adolescent Mental Health-Current Trends and Future Challenges

This extended literature review proposes to present the trends in the therapeutic alliance, outcomes, and measures in the last decade within the premises of individual cognitive behaviour therapy (CBT) and its innovations, used as an interventional measure in the context of child and adolescent mental health setting. A brief background of the rationale for conducting this literature search is presented at the start. This is followed by the methodology and design which incorporates the inclusion and exclusion criteria and the basis for the same. The critical appraisal of the primary studies is presented in the literature review section with a brief description of the summary features of the studies in the study tables followed by the results and discussion of the study findings. To summarise, the literature review of primary studies conducted in the last decade demonstrates the need for further research to be conducted both in the field of CBT in children and therapeutic alliance, competence, and therapy outcomes, integrating perspectives in child development, carer alliance, and the social construct theory in children, to allow for further innovations in CBT in the context of increasing challenges in the current times of exponentially developing technology and its utility without compromising the quality of therapy. In conclusion, recommendations are made as a guideline for future studies and research in this field.

Implementing Cognitive-Behavioral Therapy in Children and Adolescents with Anxiety Disorders

This article provides an introduction and overview of the cognitive-behavioral treatment approach to anxiety disorders in children and adolescents. We first provide an introduction to the cognitive-behavioral conceptualization of anxiety, emphasizing the tripartite model of emotions: cognitions, physiological arousal, and avoidance behaviors. We then provide an overview of the basic principles of cognitive behavioral treatment for anxiety disorders in children and adolescents, including generalized, social, and separation anxiety, and specific phobia. We follow this introduction and overview with a discussion of the structure and goals of treatment, including the three phases of treatment (psychoeducation, application, and relapse prevention). In the context of discussing application, we focus primarily on implementation strategies relating to behavioral exposures and cognitive restructuring. We conclude with a summary of different formats wherein cognitive-behavioral treatment can be implemented, including child-only, peer-group, parent-involved, and telehealth.

Conducting Exposure-Based Groups via Telehealth for Adolescents and Young Adults With Social Anxiety Disorder

The rapid spread of COVID-19 and subsequent social distancing measures posed unprecedented challenges in providing mental health care and a swift transition of services to telehealth platforms. Social distancing measures create unique concerns for young people with social anxiety disorder who already struggle with social connection and isolation; therefore, the continuation of care via telehealth platforms is especially important for this population. To date, there is little literature regarding use of telehealth groups for this population and the current commentary aims to fill in this gap in the literature while also providing general guidelines for telehealth groups. The commentary discusses the delivery of an exposure-based cognitive behavioral therapy group for adolescents and young adults via telehealth and provides considerations, challenges, and benefits of conducting a group through a telehealth platform. In conjunction with clinically relevant examples and in-depth exposure discussions, we aim to provide guidance for youth-focused practitioners who are considering conducting groups in a telehealth format for a range of presentations.

Rebooting Mental Health Care Delivery for the COVID-19 Pandemic (and Beyond): Guiding Cautions as Telehealth Enters the Clinical Mainstream

Across the COVID-19 pandemic, we have witnessed perhaps the field’s largest and most abrupt transformation in scope of practice. In the context of surging mental health needs and historically limited feasibility of traditional office-based services during the pandemic, telehealth has launched into the clinical mainstream and has become a dominant mode of outpatient mental health care delivery. The articles in this terrific Special Issue outline some of the field’s most exciting innovations from the past 18 months. The present commentary discusses how these unprecedented times have prompted unprecedented resourcefulness and innovation in the field. Issues related to evolving and uncertain telehealth regulation and reimbursement policies are discussed, and cautions for the road ahead are offered as we prepare for post-pandemic practices. The commentary concludes with a call to redouble efforts to move beyond the use of telehealth to largely treat only those populations who already enjoyed access to traditional office-based services. Understanding and overcoming barriers to telehealth care and ensuring equitable access to telehealth options are critical steps for actualizing the great potential of telehealth strategies for increasing the reach of supported care to underserved populations.

Therapist-Led, Internet-Delivered Treatment for Early Child Social Anxiety: A Waitlist-Controlled Evaluation of the iCALM Telehealth Program

Despite recent advances in the treatment of early child social anxiety, the broad accessibility of brick-and-mortar services has been limited by traditional barriers to care, and more recently by new obstacles related to efforts to slow the spread of COVID-19. The present waitlist-controlled trial examined the preliminary efficacy of a family-based behavioral parenting intervention (i.e., the iCALM Telehealth Program) that draws on Parent-Child Interaction Therapy and videoconferencing to remotely deliver clinician-led care for anxiety in early childhood. Young children (3-8 years) with a diagnosis of social anxiety disorder (N = 40; 65% from ethnic/racial minority backgrounds) were randomly assigned to iCALM or waitlist. Intent-to-treat analyses found that at post, independent evaluators classified roughly half of the iCALM-treated children, but only 6% of waitlist children, as "Responders" (Wald test = 4.51; p = .03). By Post, iCALM led to significantly greater reductions than waitlist in child anxiety symptoms, fear, discomfort, and anxiety-related social impairment, and also led to greater improvements in child soothability. By 6-month follow-up, the percentage of iCALM-treated children classified as "Responders" rose to roughly 60%. Exploratory moderation tests found iCALM was particularly effective in reducing life impairments and parental distress among families presenting with higher, relative to lower, levels of baseline parental accommodation. The present findings add to a growing body of research supporting the promise of technology-based strategies for broadening the portfolio of options for delivering clinician-led mental health services.

A Systematic Review on TeleMental Health in Youth Mental Health: Focus on Anxiety, Depression and Obsessive-Compulsive Disorder

Background and Objectives: The Internet is widely used and disseminated amongst youngsters and many web-based applications may serve to improve mental health care access, particularly in remote and distant sites or in settings where there is a shortage of mental health practitioners. However, in recent years, specific digital psychiatry interventions have been developed and implemented for special populations such as children and adolescents. Materials and Methods: Hereby, we describe the current state-of-the-art in the field of TMH application for young mental health, focusing on recent studies concerning anxiety, obsessive-compulsive disorder and affective disorders. Results: After screening and selection process, a total of 56 studies focusing on TMH applied to youth depression (n = 29), to only youth anxiety (n = 12) or mixed youth anxiety/depression (n = 7) and youth OCD (n = 8) were selected and retrieved. Conclusions: Telemental Health (TMH; i.e., the use of telecommunications and information technology to provide access to mental health assessment, diagnosis, intervention, consultation, supervision across distance) may offer an effective and efficacious tool to overcome many of the barriers encountering in the delivery of young mental health care.

Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment

In-person psychotherapy (IPP) has a long and storied past, but technology advances have ushered in a new era of video-delivered psychotherapy (VDP). In this meta-analysis, pre-post changes within VDP were evaluated as were outcome differences between VDP versus IPP or other comparison groups. A literature search identified k = 56 within-group studies (N = 1681 participants) and 47 between-group studies (N = 3564). The pre-post effect size of VDP was large and highly significant, g = +0.99 95% CI [0.67-0.31]. VDP was significantly better in outcome than wait list controls (g = 0.77) but negligible in difference from IPP. Within-groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and posttraumatic stress disorder (PTSD) (each with k > 5) had effect sizes nearing 1.00. Disaggregating within-groups studies by therapy type, the effect size was 1.34 for CBT and 0.66 for non-CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g = 0.54. In conclusion, substantial and significant improvement occurs from pre- to post-phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in-person, with efficacy being most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence.

Videoconferencing psychotherapy for couples and families: A systematic review

The delivery of videoconferencing psychotherapy (VCP) has been found to be an efficacious, acceptable and feasible treatment modality for individual therapy. However, less is known about the use of VCP for couple and family therapy (CFT). The focus of this systematic review was to examine the efficacy, feasibility and acceptability of using VCP as a treatment delivery modality for CFT. A systematic search was conducted, data relating to efficacy, feasibility and acceptability were extracted from included studies. The search returned 7,112 abstracts, with 37 papers (0.005%) included. The methods of the review were pre-registered (PROSPERO; CRD42018106137). VCP for CFT was demonstrated to be feasible and acceptable. A meta-analysis was not conducted; however, results from the included studies indicate that VCP is an efficacious delivery method for CFT. Recommendations for future research and implications regarding clinical practice are made, which may be of interest to practitioners given the COVID-19 pandemic.

A Perspective on Client-Psychologist Relationships in Videoconferencing Psychotherapy: Literature Review

BACKGROUND

During the COVID-19 pandemic, people have been encouraged to maintain social distance. Technology helps people schedule meetings as remote videoconferencing sessions rather than face-to-face interactions. Psychologists are in high demand because of an increase in stress as a result of COVID-19, and videoconferencing provides an opportunity for mental health clinicians to treat current and new referrals. However, shifting treatment from face-to-face to videoconferencing is not simple: both psychologists and clients miss in-person information cues, including body language.

OBJECTIVE

This review proposes a new theoretical framework to guide the design of future studies examining the impact of a computer as a mediator of psychologist-client relationships and the influence of videoconferencing on the relationship process.

METHODS

We conducted a literature review including studies focused on communication and key concepts of the therapeutic relationship and therapeutic alliance.

RESULTS

Studies have reported that clients are generally satisfied with videoconference therapy in terms of the relationship with their therapists and the establishment of the therapeutic alliance. Conversely, studies indicate that psychologists continue to highlight difficulties in establishing the same quality of therapeutic relationship and therapeutic alliance. The contrasting experiences might underlie the differences in the type of emotional and cognitive work required by both actors in any therapy session; furthermore, the computer seems to take part in their interaction not only as a vehicle to transmit messages but also as an active part of the communication. A new model of interaction and relationship is proposed, taking into account the presence of the computer, along with further hypotheses.

CONCLUSIONS

It is important to consider the computer as having an active role in the client-psychologist relationship; thus, it is a third party to the communication that either assists or interferes with the interaction between psychologists and clients.

Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19

The novel coronavirus (COVID-19) pandemic has caused widespread disruption to our traditional way of life and mental health therapy has not been spared. A combination of increased anxiety, diminished social opportunities, and the shift to telehealth service provision presents particular challenges for the treatment of social anxiety in youth, which relies heavily on exposures to social situations with peers, adults, or other feared social stimuli. The objective of this commentary is to provide guidance to clinicians working with youth with social anxiety on how to maintain ethical, evidence-informed provision of exposure therapy in light of these unusual circumstances. We first present an overview of how COVID-19 may uniquely impact youth with social anxiety and highlight the importance of continuing to provide exposure-based treatments during this time. We then discuss guiding principles for delivering exposure therapy during COVID-19. We focus on providing practical examples of how common social anxiety exposures can be adapted and delivered successfully through telehealth while abiding by COVID-19 social distancing guidelines. Finally, we discuss key recommendations to assist clinicians in moving treatment forward while considering changing safety guidelines pertaining to COVID-19.

Challenges and opportunities of remotely working from home during Covid-19 pandemic

The demand of online remote working from home significantly increased in 2020/21 due to the Covid-19 pandemic. This unforeseen situation has forced individuals and organisations to rapidly train employees and adopt the use of on-line working styles, seeking to maintain the same level of productivity as working from the office. The paper outlines a survey conducted amongst people working from home to identify the challenges and opportunities this change in workstyle offers. At the beginning of the pandemic, many employees faced difficulties adapting to using online tools and combining their working hours with daily routines and family commitments. However, the results show that within a short period of time the respondents had managed to develop the necessary experience and knowledge for digital working utilising tools such as collaboration platforms and video conferencing. A large proportion of respondents recognised the advantage of eliminating travelling time when working remotely from home which also has a positive impact on the environment and CO2 emissions. However, some drawbacks have been identified such as the lack of face-to-face discussion and informal meetings during working days. The Self-Determination Theory is discussed within the context of this paper and it has been found that the theory could provide an explanation of the efficient and rapid adaptation of the technology be employees.

Pediatric behavioral telehealth in the age of COVID-19: Brief evidence review and practice considerations

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

Experiences of Mental Health Clinicians and Staff in Rapidly Converting to Full-Time Telemental Health and Work from Home During the COVID-19 Pandemic

Background: The mitigation strategies for the COVID-19 pandemic pushed much of the mental health workforce to rapidly convert to full-time telemental health (TMH). For many people, this occurred in the context of working from makeshift home offices with novel distractions. We describe the results of an online survey of mental health clinicians and staff regarding their experiences in rapidly converting to full-time TMH and work from home (WFH) during COVID-19. Methods: Fourteen clinicians and 11 administrative staff from two outpatient mental health clinics in a large academic medical center completed the survey in May 2020. Results: More than 85% of participants rated the experience of providing or supporting full-time TMH care as "somewhat better" or "much better than expected." Clinicians and administrative staff reported perceptions that most clients were satisfied with TMH services. Identified TMH challenges included difficulty providing clinical forms and difficulties with technology. Identified benefits of WFH included lack of commute, time with loved ones, opportunities for self-care, and increased flexibility. Maintaining team cohesion and communication while working remotely, and setting boundaries between work and nonwork hours were identified as challenges. Nearly all respondents indicated a preference to continue some TMH from home in the future. Conclusions: Findings suggest that rapidly adopting TMH and WFH during a pandemic were well accepted. Should the progression of the pandemic require agile movement in and out of TMH and WFH, overcommunication and extra attention to supporting employee connection and morale are especially important.

Engagement in technology-enhanced interventions for children and adolescents: Current status and recommendations for moving forward

Treatment engagement is a primary challenge to the effectiveness of evidence-based treatments for children and adolescents. One solution to this challenge is technology, which has been proposed as an enhancement to or replacement for standard clinic-based, therapist delivered services. This review summarizes the current state of the field regarding technology's promise to enhance engagement. A review of this literature suggests that although the focus of much theoretical consideration, as well as funding priorities, relatively little empirical research has been published on the role of technology as a vehicle to enhance engagement in particular. Moreover, lack of consistency in constructs, design, and measures make it difficult to draw useful comparisons across studies and, in turn, to determine if and what progress has been made toward more definitive conclusions. At this point in the literature, we can say only that we do not yet definitively know if technology does (or does not) enhance engagement in evidence-based treatments for children and adolescents. Recommendations are provided with the hope of more definitively assessing technology's capacity to improve engagement, including more studies explicitly designed to assess this research question, as well as greater consistency across studies in the measurement of and designs used to test engagement.

Introduction to the Special Issue: Integration of Technological Advances in Cognitive-Behavior Therapy

A wide range of technological approaches has been adopted in assessment and intervention using cognitive-behavior therapy (CBT). The articles that comprise this special issue cover a diversity of areas, including motion-tracking devices, ecological momentary assessment, facial recognition software to provide rapid feedback, audio and tablet-based CBT-administered procedures, web-based acceptance program for stress reduction, and videoconferencing for delivery of anxiety treatment in youth. It is expected that technological advances will continue to lead to additional advances in CBT delivery.