Telemental Health and Children: 20 FREE Minimal Supply Activities

As the Coronavirus pandemic grows, many in the mental health field are faced with the real possibility of some or all appointments needing to move to Telemental Health services.  This hit home in my practice this week as I now have my first child clients going into a self imposed “social distancing”, which is a conscious effort to reduce close contact between people.  Schools, sporting events, and large gatherings are being cancelled across the United States, even the training I was waiting all year to see. Ahhh!  So many feelings are coming up for us as therapists and the families we serve. It hit home even further today as all schools will be closed in Minnesota effective Wednesday.

There are many in the mental health community who serve young children who are feeling helpless and hopeless for how to develop a plan to move forward.  For the younger children I see, I am primarily a Child Centered Play Therapist – so nondirective.  Over the past weeks I have been faced with a choice of how to move forward as I radically accept the Coronavirus, its spread, and its impact on daily life. I have also been SO touched and moved with the way the Play Therapy community has come together to support one another, including the development of the “Tele-PLAY Therapy Resources and Support” facebook group. 

If we dive into the fears that some therapists may have about just what might happen during these appointments that hold therapists back, hopefully we can become clearer on the answers of how to move forward.  At the beginning of my Telemental Health journey I began brainstorming what were the potential risks with children specifically.  These were sessions where their parent or a guardian would be at the residence the entire duration of the session. 

Okay – so here is what my list looked like.  What if they run out of the room? What if they turn off the camera/program? What if they take the device and go on other programs? What if they don’t listen to what I say?

When I sat down to think about these things, I actually realized that I feel safer providing Telemental Health to children than adults.  Children will always have an adult I can connect with if they are having difficulties.  I developed a procedure to have parents accessible by phone for the duration of the appointment and I have easy access to their phone number and my phone.  This means, if any of these things happened, a parent would quite quickly be able to engage in the room.  I also reflected that some of these things happen within office too as part of the therapy process and most of us have a theory or procedures in place with how we handle clients not complying with limits or boundaries. Also, consider if limits may need to be set sooner to ensure the child stays in the window of tolerance to be able to engage with you.  Lastly, brainstorm for your practice what will happen if they child is not able to comply with limits? Will the session be over? Will the parent join for the remainder of the session?

Now, on to my next set of worries. What if they become distressed and begin to have a meltdown? What if they are throwing things or in physical danger?  Again, I came back to quick and easy access for parents and extra safety precautions that I clearly review policies with parents that if there is a true crisis I will call 911 and will have their address easily accessible at all times.  When I really thought about it hard, this would be no different than a child playing alone in their room for 30 or 40 minutes.  AND what I know is that children get dysregulated at home all the darn time.  How often do we hear about fights with siblings or a client completely melting down over losing a video game?  Parents are present for those situations and have been the ones “in the trenches” responding to these episodes for the child’s entire life.  You will want to have extra brainstorming and policies with parents around how they might handle this should it arise – which may look different for each client. 

Other potential difficulties I brainstormed was the child that did not want to engage in a virtual session – the child that left the room, had a tantrum when the appointment started, got bored and tuned you out - you get the picture.  When I thought about it many children are familiar with a video chat platform like Facetime of Skype so this likely won’t be their first video chat.  BUT I also know this could be very anxiety producing for children.  I then considered what “buffet of options” I could provide to support families with.  Would this be a child where parent and child sessions would be more beneficial? Would this be a client who I would meet with the parent only and potentially reduce session frequency? Would the child be receptive to certain activities over others?

Then my mind wandered to age – what if they are too young? I then began thinking about what age would I ethically consider young enough to be unsupervised in a room for 30 minutes? Yes, as an adult I would be watching virtually what was happening in the room so they wouldn’t be truly alone, but I wouldn’t be able to physically intervene.  My personal style is to check in together with parents and children, so 30 minutes is the minimum that I typically like to have with children alone. I also considered the emotional and maturity age and how this may be different with different clients.  Another solution I thought was for children who may not be able to handle 30-40 minutes, could I alter sessions and do a 90832 session OR have sessions that were family focused with the parent in the room? Another idea I had was to have the parent physically present in the room, but not in the session.  Maybe the parent has earphones in and are catching up on their favorite TV show? 

Lastly I came up with questions and worries about the technology. What if they don’t know how to work the program? Then I realized that most children are more proficient in technology than adults.  I also know that a parent setting up the technology and being able to call the parent to assist should connection be lost and a re-set is needed would be something that would be a potential solution.

As I sat down with all of this information and consulted the ACA Ethical Decision Making model I found nearly ALL of the foundational ethical principles applied.  The first was Autonomy – providing my clients and their parents the right to make a choice about how they wanted to proceed with their mental health services. Next up – non-maleficence.  How in this dilemma was I going to ensure that I was not causing harm to my clients? I weighed the pros and cons of no services (for weeks or months) OR an altered format (more directive, shorter appointments, etc.) via Telemental Health.  How could I avoid client abandonment? Then comes beneficence – what will be the decision that will be in the best interest of the client? Again, I weighed the benefits of providing this service as a new format of therapy (virtual and directive) versus no services.  Lastly is fidelity “honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships.”  How does this crisis fit with my commitment to clients? After considering these principles and weighing pros and cons of each, consulting my ethics code, state laws, board requirements, and insurance company requirements I decided the best course of action was to prepare to provide this service as an option and choice to families should they ask about it or be unable to engage in therapy due to circumstances such as quarantine.  I decided I needed to continue to offer to provide mental health services as a consistent factor in their life as well as keep the connection and relationship in uncertian times.

Interested in more about starting Telemental Health Services with children and adolescents? Take my free E-course HERE. It includes more comprehensive outline of Telemental Health services, a resource list, a “Cheat Sheet” to orient clients to Telmental Health and an informed consent template.

Now, before we get into the good bits of what this might look like, I wanted to take some more time to talk about how we roll this out to our families. If I’m being really honest, how comfortable families feel with this therapy starts with US. If they inquire about it and we are anxious, frantic, or panicked OR we don’t even have a plan, families are definitely going to feel uneasy about getting their child’s mental health needs met in this way.  I can tell you that it felt amazing to tell my clients this week “yes we can definitely set that up.  Our clinic has been working on a plan to help support clients that need or would prefer to have virtual appointments.  Here is a sheet that will help guide you though the login process and we can sign an additional informed consent and discuss the specific risks and limitations of Telemental Health”. These families – they were relieved that I had already been thinking about this and had measures in place to support the way they felt most comfortable having sessions.

When I rolled this out to the young people I was working with it sounded a little like this “There are some really big things going on in our country right now.  What do you think I am talking about? [prompting children to engage in their own language to describe the pandemic]. Yes! [paraphrase child’s response]. Now, I know your family is making some decisions with how to keep you and your family safe.  What do you know about that? [prompt dialogue in the child’s own language about the changes]. Yes! [paraphrase child’s response].  There may be a lot of changes in your life because of this like not getting to see your friends for a bit or go to the activities you like, but the good news is we will still get to meet virtually! Have you ever had a time that you talked to someone over video on the phone or the computer? [prompt a dialogue about their experiences with video chatting platforms].  Now for us, our sessions might look a little bit different.  I know most of the time you get to be in charge in here and decide what to do.  When we meet virtually I will have an activity or project set up for us and will let your parents know exactly what you need to have for our time together.  Now, what questions do you have? [prompt discussion about fears, worries, or wonders].” 

Lastly some tips of how to prepare and orient these sessions.  The most frequent question I have is how to keep the sessions private.  Brainstorm with parents what room of the house is the most beneficial for privacy and utility.  Discuss the option of playing a radio outside of the room for extra confidentiality, especially if siblings will be home.  Discuss how parents can ensure that siblings maintain good boundaries. Have them practice before hand of where to place the device.  Email parents a “supply list” of what they need to have on hand for the sessions before the session.  Evaluate the need for an altered structure.  I usually say a casual goodbye to parents in the lobby as we transition but evaluate if there may be a need for the parent to come on camera and officially end the session.  Oh and lastly – I made a commitment to my clients that I would tally how many virtual sessions we had together and they would get to pick that many treasures from my treasure box when we resumed in person sessions.  I definitely didn’t think it was fair to withhold the treasure!

Okay – now to the activities!  I actually had so much fun putting this together and the ideas just kept flowing! I created this list with the minimum amount of supplies necessary that all families likely have on hand at home!

20 Free, Low Prep, and Minimal Supply Activities for Telmental Health With Children:

1. Bibliotherapy: Giraffes Can’t Dance.  Check out my blog HERE for how I use this book for growth mindset, self esteem, regulation, and social skills. If you don’t have this book there is a link to you YouTube video of the book.  You can send the client the link through the chat feature and they can pull it up on their computer – OR if your program has a screen share it can be co-viewed this way too! This blog has a download packet of three printable worksheets to use BUT if a client does not have a printer you can ask the parents to have markers and paper ready and the client can create the worksheets themselves! Supplies: Giraffes Can’t Dance (or video), printed handouts (or computer paper), markers, crayons, pencils, or pens. Want to learn more about Bibliotherapy?  Check out this training HERE!
2. Guided Imagery: Safe Calm Space. Have kids watch Peace Out Guided Relaxation For Kids – Balloon by Cosmic Kids Yoga. Explore where their balloon took them and have them draw a picture of their safe, peaceful, calm space. Supplies: Paper, crayons, markers, or colored pencils.
3. Pick a Miniature: I LOVE miniatures. And here’s a secret – your client’s likely have a giant collection of their own miniatures in their home.  You could have clients pick a miniature for a wide variety of feelings and ask them to explain how each miniature is like that feeling.  You could have them pick miniatures to represent their strengths, their goals, or what they are like when they are with each member of their family.  The sky is really the limit here. Supplies: Have the client gather a collection of their own miniature objects.
4. Mindfulness Scavenger Hunt: Have the child do a scavenger hunt finding and collecting five things they see, four things that make noise, three things with texture, two things that smell, and one thing they taste.  Download my bundle of 5 therapeutic scavenger hunt worksheets HERE! For other ideas check out this link here. Supplies: Printer OR have the therapist read off each item one by one.
5. Gratitude Scavenger Hunt: Okay and speaking of scavenger hunts, here is a link to an amazing gratitude scavenger hunt with a free printable. I also found another example and free printable here. Supplies: Printer OR have the therapist read off each item one by one.
6. Mindfulness: Get a free printable download of 12 “Mini Mindfulness” activities for kids here and 8 free printable breathing exercises here.  Supplies: Printer (therapist only) OR read a copy of the exercises on your screen or alternative screen.
7. Bibliotherapy: Last Stop on Market Street. Check out my blog HERE for how I use this book for gratitude.  Don’t have the book? No worries – there is a version HERE that the author reads on YouTube. If you worry your client isn’t old enough to click the link the parent can sit in and the child and parent can watch the book together. Supplies: Last Stop on Market Street (or the video), a thank you card OR paper and markers, crayons, or colored pencils.
8. Emotional Hedbandz: Get these free printable feeling cards here and hold it up to the camera without looking (or disable/cover the part of the program where you can see yourself). Explore emotions by taking turns asking one question each about the emotion until both emotions (or all with family) have been identified.  The low budget version? Have the family write feeling words on small slips of paper.  BONUS if you can find elastic, string, or a headband to hold the feeling card up.  Supplies: Printer OR slips of paper to write emotion words on.
9. Emotional Regulation: Grab your emotional Regulation free download here, free anger dice game printable here, free anxiety coping skills mini card deck here, and free “anger buttons” printable worksheet here. Supplies: Printer (or read activities off the computer) and dice.  Don’t have dice? Cut out slips of paper and draw from a cup!  
10. Quick Draw: This is a Terry Kottman technique and can be found in her book Doing Play Therapy.  For this activity you agree on a fairly short time limit.  The limit doesn’t actually matter and it can be altered and flexible.  I usually go between 30 seconds and 2 minutes. Have the child get several pieces of printer paper and fold them into quarters. Each section is a new drawing. Using the time limit you instruct a child to make a new drawing in each section.  Prompts can be anything you think would fit the child and can include things like drawing their proudest accomplishment, what mad looks like, what they worry about the most, the place they are the happiest, their favorite subject in school, the last time someone was angry with them, the last time they felt guilty about something, etc.  After you go through 4-8 rapid drawings you circle back and use each drawing as a jumping off point for a discussion. Supplies: Paper and crayons, markers, or colored pencils.   
11. Mandalas: Use this amazing resource and this one to help children use mandalas to help express their inner world.  Supplies: Paper and crayons, markers, or colored pencils.   
12. Feeling Heart: Help young people understand and articulate all the complex and complicated feelings that are in their heart.  Unsure of what a feeling heart is?  Check out an example and free printable worksheet here! Supplies: Printer and crayons, markers, or colored pencils.  No printer? Have the client or their parent draw out a heart on plain paper.
13. Music Body Outlines: I talk about these amazing feeling faces here BUT they also have body outlines included in the free printables!  You can encourage the child to do a body feeling map OR one of my personal favorites play three songs of varying nervous system activation (ie soothing, happy and upbeat, angry and aggression) and have them listen to each song through.  After each song have them map out what feelings they felt, where they felt it in their body, and compare the three.  Supplies: Printer and crayons, markers, or colored pencils. Don’t have a printer?  Coach their parent to make three sheets “ginger bread man style” body outlines.
14. Recipe for a Good Friend: Use the book This Moose Belongs to Me to process what it means to be a “good friend”.  Process what expectations Marcel has for his moose and if they are realistic.  Don’t have the book – watch the video here! Develop your own recipe for a good friend with this free download.  Be creative and check in with parents ahead of time about what snack objects may be on hand at home.  Brainstorm what ingredients are used to make up a “good friend” and include a recipe of how to put it all together.  The sky is the limit!  For fun you can use trail mix to identify each trait (ie. raisins = fun, M&Ms = loyalty, etc.).  You can also alter this for what it means to be a good family member and enjoy the snack as a family!  Lastly – if there is no way to have the actual trail mix – brainstorm what would be in the mix and you can use this as a bridging activity and make the actual trail mix when you are back in the office! Supplies: Printer and crayons, markers, or colored pencils. Snack food to make a “trail mix”.  Don’t have a printer?  Use a blank sheet of paper to create a recipe or snag a parent’s blank recipe card.
15. Big Feeling Eaters: Check out my blog post here about Big Feeling Eaters complete with how to make this emotional containment activity out of a Kleenex box.  This is a great strategy for emotional regulation!  Are you worried the family you work with won’t have a Kleenex box?  You can make this activity out of an envelope (because almost EVERYONE has those) or to be honest with some thoughtfully folded and taped paper.  Check out some examples here and here! Supplies: Kleenex box, craft paper/wrapping paper, and art supplies OR envelope and art supplies.
16. Yoga: Cosmic Kids Yoga has an amazing YouTube channel with a TON of exciting yoga practices (Frozen, Harry Potter, or Pokémon anyone?) OR download these FREE kids animal yoga pose cards. Supplies: Yoga mat OR a towel works just fine!
17. UNO: You can play UNO online with clients using sites such as this one. Use the same “therapy rules” you have in office.  My favorites are identifying feeling triggers, warning signs, and coping skills for every color switch.  For me green = anxious, blue = sad, yellow = happy, and red = mad.  Don’t have a screen share option?  You can use what is called a “Tab Resize Extention” for Google Chrome to allow the screen to split.  Supplies: None!
18. Sand Tray: Okay – now most of our clients do not have a sand tray on hand at home.  BUT most of them have miniature toys and computer paper.  For this activity have the client or parent tape together four sheets of computer paper in a rectangle.  Have the child or parent gather up the typical “categories” including people, animals, fantasy figures, plant life, minerals, environments, transportation, miscellaneous objects.  You can have the client start out by drawing what kind of ground the “tray” will have on the paper. Then, do your sand tray work as usual! Supplies: Miniatures, art supplies, paper.  
19. New Tune, New Mood: Identify with the child what mood they would like to have in the moment.  This could be happy, excited, calm or anything else.  Create a playlist with the child of their favorite songs that get them in this mood.  They could design an album cover and list the songs out.  You can play the songs together and encourage the child to move their body in what ever way feels comfortable for them.  Supplies: Paper and crayons, markers, or colored pencils
20. Holding on and Letting Go: Have the child trace each one of their hands.  In one hand (or just use the fingers if you want less prompts) write what the child has control over.  You can write a list draw pictures, or a combination of both.  In the other hand write what the child doesn’t have control over and needs to “let go”.  Again - use words, pictures, or a combination.  For further deepening you could have the child separate the page and “destroy” what needs to be let go.  That could be ripping it up, crumpling it, throwing it in the garbage, etc.  Supplies: Paper and crayons, markers, or colored pencils.

 
Here are some additional things to consider – all online programs you are asking clients to use should have informed consent from a parent and clear communication about why you would like the child to access such a program.  You should never engage in the chat feature of any online shared program (if applicable) as it is not HIPAA compliant. Lastly – if there are no markers, colored pencils, or crayons to be found in the home you can have the child draw different patterns to symbolize different aspects and create a “key” of sorts to code it all out.

I hope this gets your wheels turning about free and low prep activities that you could modify to work well with Telemental Health child clients! We are creative. We are play therapists. WE CAN DO THIS! ​

Interested in more training? Check out my Cognitive Behavioral Play: Low Cost and Preparation Training for Telemedicine and Tele-Play that is  approved for 3.25 APT Non-Contact hours by Meehan Mental Health Services (APT Approved Provider 19-580).

Drop a comment with your favorite free, low cost, low prep activities that you are thinking about using for Telemental Health with kids!
 
 

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