Tag Archives: Children & Adolescents

Children & Adolescents

Addressing problematic internet use with youth and families

By Stephen V. Flynn November 20, 2023

close up of a teenager on their phone; legs crossed; phone in hands

Stock Rocket/Shutterstock.com

Making healthy decisions regarding our screen time and internet use can be challenging and often requires a fair amount of self-discipline. We may ask ourselves, “Why am I looking at my cellphone again?” or “Why did my screen time report go up by 15% this week?” Many families are struggling with these questions and are trying to find unique ways to manage their time online, so the counseling profession should be informed of research-based standards related to helping parents and caregivers with child and adolescent online usage.

Parents of young children and tweens often feel guilty and confused about childhood internet standards and whether it is OK to use screen time as a reinforcer for good behavior or to use the internet as a distraction so that the parents can focus on other tasks. Similarly, parents of teenagers often feel confused about when to give their teen or tween a personal cellphone, when to collect a teen’s phone or tablet so that they focus on homework, and how to discipline their adolescent for inappropriate internet use (e.g., viewing pornography, sharing personal content with strangers, engaging in online bullying).

Counselors may also experience some confusion as to what constitutes healthy and unhealthy internet use, what are appropriate age-based internet standards, what position parents should take in particular areas of adolescent internet use (e.g., pornography, social media, gaming) and how they can work with families to help reduce internet usage when it becomes a problem.

When I bring up the topic of appropriate internet usage in the family counseling class I teach every year, it is the contemporary issue that elicits the most controversy with counseling students representing different generations. Typically, the Gen Xers take a more conservative and concerned stance against excessive internet use, while the millennials and Gen Zers appear somewhat defensive over any criticism related to internet use. As a clinician and supervisor, I often notice the same patterns in clinical practice.

The potential dangers of internet use

Internet addiction is marked by extensive and constant use of the internet despite negative consequences. It should be noted, however, that despite being widely researched and experienced, internet addiction is not a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. Nevertheless, it’s important that counselors understand the nuances of internet addiction given the prevalence of technology in modern life.

According to Najah Almukhtar and Saad Alsaad in a 2020 article published in the Journal of Family Medicine and Primary Care, signs of this behavioral addiction include:

  • A loss of control that eventually leads to distress due to spending an excessive amount of time engaging in recreational internet use (e.g., visiting social media sites, surfing the web for information, gaming)
  • Cravings when not using the internet
  • Planning and preoccupation about internet use when not online
  • Functional impairment in daily life
  • A variety of potential physical concerns (e.g., obesity, poor eyesight, carpal tunnel syndrome, headaches, dry eyes, poor sleep patterns, backaches)

Additionally, in a 2015 article in the journal PLoS ONE, Wen Li and colleagues described psychological issues that can emerge because of internet addiction and pathological internet use, including social anxiety, increased attention-deficit/hyperactivity disorder symptomatology, self-injurious behavior, challenges with concentration and sleep deprivation.

A concerning contemporary issue that can be difficult for parents and caregivers to discuss is pornography use by children and adolescents. Hardcore pornography is now available to internet users all the time. According to Paul Wright and Aleksandar Stulhofer in a 2019 article on adolescent pornography use published in Computers in Human Behavior, parents and caregivers often fear how accessible pornography is to children, the content and nature of the pornographic videos being consumed, and youth’s inability to separate fantasy from the facts surrounding most nonpornographic sexual relationships.

In a 2011 article published in Aggressive Behavior, Michele Ybarra and colleagues explored pornography use in youth 10 to 15 years of age and found that long-term intentional exposure to violent X-rated media predicted a nearly sixfold increase in the likelihood of self-reported sexually aggressive behavior. These authors also discovered that deliberate exposure to nonviolent X-rated material was not related to a statistically significant increase in sexually aggressive behavior toward others.

A final area of extreme concern for many parents and caregivers has to do with protecting children from online predators. Adult online predators can deceive and lure youth into sexual encounters, sexually abusive situations, bullying, identity theft and sex trafficking. Common internet-based platforms and devices used by online predators to make contact, socialize, and eventually exploit children and adolescents include social media sites, cellphones, chat rooms, video game consoles, apps and app-based video games, and instant messaging. These platforms allow predators to access potential victims in an anonymous, distant and discreet manner to increase the opportunity for deception and manipulation.

Establishing healthy boundaries with internet use

Problematic use of the internet has the potential to devastate lives and cause significant distress within youth and families. Yet excessive, dangerous and illegal internet behavior remains largely unregulated by the government, and the monitoring and responsibility of appropriate child and adolescent use fall to parents and caregivers.

Counselors are in a unique position to support youth and parents when it comes to issues related to the internet. There are a wide range of potential modalities, theories and interventions to assist in problematic internet use. Parent counseling, family counseling, cognitive behavior therapy, reality therapy, family meetings, psychoeducation, collaborative homework, motivational interviewing and the use of third-party parental control apps are useful in exploring or reducing screen time usage and for protecting youth from potentially harmful sites and images.

Psychoeducation centered on educating families on the potential negative effects of excessive screen time use can be extremely important. Counselors can broach this topic when discussing family rules for internet use. For example, the following conversation is a hypothetical parent counseling exchange between a practitioner and two parents (Lisa and Frederick) who are concerned about their children’s screen use. Although this example is focused on a parent counseling experience, a similar conversation could take place during a family counseling session or during a parental consultation session.

Counselor: You are fearful that screens are serving as a substitute for parenting. I wonder if you’ve considered creating boundaries around when your children are permitted to use their cellphones.

Lisa: I think that’s a great idea.

Frederick: Right now, we don’t have anything formal in place, and their grades are poor.

Counselor: A good area to start is discussing when they should put their devices away.

Lisa: The two older boys typically start homework around 7 p.m., so that would be a good time to collect their cellphones.

Counselor: When would you give them their phones back?

Lisa: Before they head off to school.

Frederick: Let’s say 7 a.m.

Counselor: Some families have different screen time rules for the weekends. What are your thoughts?

Frederick: I think they can have their phones at 5 p.m. on the weekend. We can collect them before they go to bed.

Lisa: Agreed.

There is general agreement that complete avoidance of the internet should not be the goal of treatment. The goals should be more in line with helping parents and youth use the internet safely and responsibly and find a sense of balance and control with using the internet.

Counselors can provide families with referral sites, such as the Center for Internet Addiction and the Center for Internet and Technology Addiction, that provide helpful information and support on technology use.

Screen time issues can also be addressed in a collaborative family homework assignment. In the example of Lisa and Frederick, the counselor may work with them to establish a plan for screen use and ask them to implement it at home:

Counselor: It sounds like the family is continuing to consider a healthier screen time schedule.

Lisa: Yes, do you have any suggestions for us?

Counselor: It sounds like you have already created an initial setup. The two older brothers, Philippe and Anthony, have agreed to curb their usage and increase their homework time by handing in their cellphones at 7 p.m. every weekday evening.

Frederick: That would work for the two teenagers, but what about Ariel?

Counselor: As a 5-year-old, Ariel doesn’t really need much screen time, and it isn’t all that healthy for her. The previous discussion centered on allowing her to watch weekend cartoons and one movie.

Lisa: Sounds like we have a plan.

Frederick: Sounds fine.

Counselor: OK, let’s agree to follow these standards for the upcoming week. During our next session, I’ll check in to see how it all went.

Parents and caregivers often worry how internet use may affect children’s safety, mental and physical health and social development. These example conversations illustrate how counselors can help caregivers establish healthy, age-appropriate rules regarding internet and screen use and facilitate productive conversations when their child witnesses something disturbing such as extreme violence or pornography.

Considering the clients’ developmental level

Counselors must consider the clients’ development level and needs when assessing and treating problematic internet use. When working with adults, counselors should educate them on the addictive nature of the internet, increase awareness around how internet use is affecting their life (e.g., career, relationships, happiness, finances), reduce any shame or blame related to internet use, explore alternative non-internet activities and encourage the person struggling with problematic internet usage to find coping skills and a safe person to talk with (other than the counselor). Unlike children and adolescents, adults often have a much greater capacity for personal responsibility, introspection, self-awareness and self-discipline. This is an important factor to consider when collaborating on out-of-session work related to issues such as reducing screen time and refraining from engaging in certain websites.

Counselors who specialize in working with children, however, should recognize that issues such as awareness, personal responsibility, introspection, self-discipline and difficulty resisting the addictive nature of the internet can serve as barriers to children limiting their own internet use.

If possible, counselors should ensure that parents and caregivers are part of the treatment. This can come in the form of weekly or biweekly parental consultations or periodic check-ins. During these meetings, parents can discuss strategies and goals for reducing screen time. Counselors should also empower parents to create rules that promote healthy screen time usage. General guidelines on children’s media use and family tools can be found on the American Academy of Pediatrics website and on the World Health Organization’s website.

Counselors should remind parents that the shape and scope of internet usage changes for adolescents and that parental flexibility is key. Screen time for teenagers often includes doing schoolwork and projects, watching TV shows, streaming videos, creating art or music online, gaming, connecting with peers via social media and watching fast stimulation online content (e.g., TikTok). Because a lot of teenagers’ screen use involves addictive mediums such as apps, gaming and social media, parents should recognize that their adolescent children can be tempted to spend far too much time online. This heavy usage can cause a variety of negative consequences, such as sedentary lifestyle, obesity and mental health issues.

Establishing healthy rules around technology can be challenging because families often include youth living together who are of different ages and at different developmental levels. Counselors can help parents balance general household standards and rules (e.g., no pornography, no computers after 9 p.m.) with more specified internet usage rules relevant to each child’s developmental level. Although many internet-based parenting issues and supervision concerns can be solved if computers are kept in a common area, this might not be possible for older teenagers who require more independence and have personal cellphones.

Counselors may feel overwhelmed with the balance of encouraging developmentally appropriate independence and helping parents with household expectations regarding devices. While there is no quick and easy solution to this issue, working with families to try to have achievable expectations and to blend family rules with individually tailored expectations appears to be key to long-term therapeutic success.

Issues involving inappropriate internet use, screen time standards and protection from individuals who exploit youth online are not new concerns. Counselors need to be aware of the various issues and problematic behavior that can affect those who are addicted to or abuse the internet. Our efforts as counselors should be centered not only on openly exploring and processing these concerns but also on actively engaging with individuals, families and communities to develop standards for healthy internet use.


Learn more about working with families on issues related to internet use in Flynn’s latest book, The Couple, Marriage, and Family Practitioner: Contemporary Issues, Interventions, and Skills. This comprehensive guide examines contemporary issues, theories, interventions and skills related to working in the interrelated fields of family, couple and child-based counseling.


headshot of Stephen Flynn


Stephen V. Flynn is a professor of counselor education, a research fellow, the founding director of the marriage and family therapy program, and the play therapy program coordinator at Plymouth State University in Plymouth, New Hampshire. He is a licensed professional counselor (Colorado), a licensed marriage and family therapist (Colorado and New Hampshire), a national certified counselor, an approved clinical supervisor, an American Association for Marriage and Family Therapy (AAMFT) Clinical Fellow and an AAMFT Approved Supervisor.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Treating anxiety in children

By Lisa R. Rhodes August 7, 2023

A counselor sits in a circle with a group of kids. The counselor has a notepad and pen and is giving two of the kids high fives.


Childhood is quickly becoming a time of increased worry and emotional distress. According to a Department of Health and Human Services study published in the Journal of the American Medical Association in March 2022, the number of children aged 3 to 17 diagnosed with anxiety grew by 29% between 2016 and 2020. In fact, medical and mental health professionals have become so concerned about the increase in childhood anxiety that last October the U.S. Preventive Services Task Force called for health care professionals to begin screening for anxiety in children aged 8 to 18.

Counselors who treat children for anxiety, specifically those aged 6 to 12, say the rise in childhood anxiety is due in part to the fast pace of modern society as well as the onset of COVID-19. “Our culture [is one] of busyness, constantly moving with lots of good opportunities, but almost too many good opportunities, keeping kids busy with structured learning instead of learning through observation and play,” says Hannah Pitman, a licensed professional counselor (LPC) at Abundant Life Counseling Services in Austin, Texas. “Kids are forced to make so many more microdecisions every day that their brains get on overload. They are constantly in communication and contact with everyone … at any time.”

A child’s life used to be less complicated, she continues. They went to school, played during recess, came home, ate dinner and went to bed. But today, there are more activities for children and more decisions to make. For example, after school, do they go to gymnastics, play soccer, attend piano lessons or chat with friends on social media?

“As our culture has [evolved], decisions and opportunities have grown,” Pitman says, noting that a child’s brain needs these opportunities to be given by parents in smaller doses so there will be less psychological stress for them.

Pitman and Aileen Elsaesser, an LPC at Sunstone Counseling in Alexandria, Virginia, note that genetic and environmental factors both play a role in children developing anxiety and displaying anxiety-related symptoms (e.g., feeling nervous, having temper tantrums, catastrophic thinking). Elsaesser says children who grow up in an environment where parents or caregivers display anxious behaviors or who have experienced a stressful event (e.g., moving to a different state, being in a car accident, losing a loved one to a terminal disease, being bullied) may develop a tendency toward anxiety.

Children want to play and have fun, but anxiety takes away their ability to play uninhibited and enjoy life, says Pitman, who treats children and adolescents with anxiety disorders. “Normal levels of worry and stress impact us, but not in a way that they make our daily lives overly difficult,” she explains. “When anxiety starts to impact a child’s ability to function and enjoy life, that’s when it’s time to make a change.”

Assessing for anxiety

Parents play a pivotal role when assessing children for anxiety. Elsaesser recommends counselors have parents participate in the intake process because they know their children best and can be helpful in answering questions about the child’s emotions and behavior.

“Clinicians will perform a detailed intake evaluation with the parents to discuss symptoms, severity and functioning of the child,” says Elsaesser, who specializes in treating children struggling with anxiety and phobias. “We ask for physical symptoms, anxious thought patterns, behaviors indicating anxiety and how it is affecting functioning in different areas of the [child’s life].”

Elsaesser recommends counselors use the Screen for Child Anxiety Related Emotional Disorders Assessment with both parents and children during intake. This self-report assessment screens for general anxiety disorder, separation anxiety disorder, panic disorder and social phobia in youths aged 8 to 18. The assessment statements for children (e.g., “When I feel frightened, it is hard to breathe,” “I don’t like to be with people I don’t know well”) and parents (e.g., “My child worries about other people liking him/her,” “When my child gets frightened, he/she feels like passing out”) are rated on a scale of 0 (not true or hardly true) to 2 (very true or often true).”

Elsaesser says the assessment gives her insight into a child’s understanding of their own anxiety and what parents may notice but the child does not recognize. The information from these assessments helps her formulate a treatment plan, but she notes that screening is not the sole determining factor for diagnosis.

Pitman often asks her clients’ parents if they have noticed any changes in their child’s behavior or if it is affecting the child’s daily functioning. To determine this, she tells parents to ask themselves the following:

  • Is my child having trouble going to school every day?
  • Is my child unable to enjoy fun events?
  • Is my child obsessing over something or someone?
  • Is my child feeling afraid more often?
  • Is my child irritable every day and unable to control their emotions?

For example, if a child refuses to attend school, has trouble concentrating in school, avoids sleepovers and parties or doesn’t try new things or if their physical symptoms (such as stomachaches or headaches) cause them to be impaired, then the parents should consider having their child assessed for anxiety.

Jena Jozwicki, a licensed associate counselor at Elevate Counseling in Glendale, Arizona, says she uses her own checklist of questions to screen children for generalized anxiety disorder. These questions include:

  • How long have you been feeling this way?
  • How often do these anxiety attacks occur?
  • When do you notice the symptoms most?
  • How do you know you are experiencing anxiety?

These questions allow Jozwicki to understand the severity and frequency of the child’s anxiety symptoms so she can best classify and make a diagnosis.

Determining an effective treatment plan

The counselors interviewed for this article agree that cognitive behavior therapy (CBT) is an effective treatment for anxiety disorders because it helps children become familiar with their distressing thoughts and learn how to replace them with healthy thinking patterns. It can also help them learn to become more aware of their emotions and how they influence their behavior.

Counselors should also consider working with parents during therapy because family members can be helpful in teaching children how to recognize anxiety and implement the coping skills and behaviors they learn in treatment.

Pitman devotes the first few sessions of therapy to helping children build emotional and relational skills and determining what modality will work best for the child and their family. She often finds CBT, trauma-focused CBT, eye movement desensitization and reprocessing, internal family systems and trust-based relational intervention work well for her clients. She also uses the information she gleans from these first few sessions to help her later assess if the child is progressing or regressing.

During the first therapy session, Pitman meets only with the parents to establish rapport and learn more about what the child is struggling with, without having to use age-appropriate words or timing. Pitman asks parents, “What are you hoping I can help you with?” and “What have you tried already?”

Pitman wants to know if the parents have a good understanding of anxiety or if this is their first time encountering it. This helps her determine how much psychoeducation about anxiety is needed at the start of therapy. She also discusses the importance of parents spending quality time to connect with their child and to be empathetic to validate the child’s experience and let them know the parent is there to help them manage their anxiety.

Pitman devotes the second session to helping the child and parent(s) build rapport for the work they will do together in session. She says she usually begins this session by asking the child and parent(s) to play a trust-based relational intervention connection game to increase co-regulation between the child and parent and build communication to disarm shame and confusion around anxiety in the home.

“When a child’s home is an open place to talk about their needs, they are better able to manage their anxiety,” Pitman adds.

One connection game she often has her clients play involves the use of Band-Aids. Pitman asks the parents and child to share a happy and a sad thing that happened to them during the week. Then the parents put a Band-Aid on the child for their sad thing, which shows empathy and care, and the child puts a Band-Aid on the parent for their sad thing. This activity is one of Pitman’s favorite games because it helps children build emotional and communication skills, allows parents to model how to talk about positive and negative feelings, and lets parents and children practice giving and receiving care. Even the simple act of asking where the person would like them to place the Band-Aid helps build the skill of asking permission and negotiating emotional needs.

After playing the game, Pitman works with the child alone, if they are comfortable, to build rapport, and she incorporates psychoeducation to teach them about the purpose of therapy and normalize their experience with anxiety. For example, she may ask, “What do you know about counseling?” and “Sometimes kids worry and feel like they can’t stop. Have you ever felt that way? Did you know that a lot of other kids often feel that way?”

Pitman continues to meet with both the parents and child during the third and fourth sessions and keeps her focus on building rapport and introducing the child to breathing exercises, which can be fully implemented in later sessions.

“These [early] sessions give you time to build rapport and determine the severity of the child’s anxiety,” Pitman explains. “Once you have seen that, you are able to see if there is something deeper the child needs to process, like trauma, or if it is general anxiety.”

Pitman says a counselor can also learn where the family stands in terms of the child’s treatment. Are the parents able to complete the assigned activities at home? Can the parents help the child manage their anxiety or are they dealing with their own anxiety and are not able to help? The answers to these questions help counselors determine a treatment plan for the client, she notes.

Learning to handle distress

Elsaesser recommends teaching clients distress tolerance skills because they can use these skills throughout their lifetime whenever they encounter stress. She provides a hypothetical example to illustrate how counselors can help children struggling with anxiety learn to manage physical symptoms and de-escalate anxious thoughts by evaluating and reframing them.

Eric is 9 years old and has been struggling with separation anxiety for several years. His parents are not aware of any specific incident that caused his anxiety, but his mother’s side of the family has a history of anxiety disorders. When Eric begins counseling, he presents with several anxiety symptoms, including worrying that something bad might happen to his parents. He becomes nervous and stressed if his parents are not near him. He calls his parents multiple times throughout the day to check on them. Every time they leave, even when he knows where they are and when they will be home, he asks repetitive questions for reassurance, such as “Where are you?” “When will you be home?” “Are you going out tonight?” “Who will put me to bed?”

He tells the counselor he is experiencing stomachaches, a rapid heartbeat, fast breathing, shakiness and muscle tension, and he has a difficult time concentrating when he is worried or nervous about his parents’ whereabouts.

In therapy, Elsaesser says she would teach this client relaxation and coping techniques to handle his physical symptoms. She would first ask him to draw a picture of his body and to point out all the places where he experiences physical symptoms. Then she would normalize his experience by telling Eric that the symptoms are common in people who struggle with anxiety.

Once Eric knows what anxiety looks and feels like in his body, Elsaesser would encourage him to name these bodily symptoms when they arise. For example, he may say, “My stomach hurts because I am worried about being alone.” She would also have him practice relaxation techniques, such as deep breathing and tensing and releasing his body through progressive muscle relaxation.

Elsaesser would use CBT techniques to help him get control of his thoughts. She would discuss thoughts versus facts and helpful/useful worries versus unhelpful/useless worries. “I would explain that helpful worries keep us safe, like how worrying about getting injured by a car makes us look both ways, but unhelpful worries keep us from living joyfully or doing the things we want to do,” she explains.

Elsaesser says she would then ask Eric to imagine the worst-case scenario for his parents. He may say that his parents could fall and get hurt when they are walking the dog, and if no one knows, they would be stuck there alone. She would also ask him how likely it is that would happen. He may admit that it is not likely but insist that it could still happen.

Elsaesser says she would then shift the focus to how he would handle the situation by asking, “OK, so it’s not very likely, but would you be able to handle it if that happened?” Eric may respond by saying, “No, because they’d be hurt, and I’d be so worried and sad.” She would validate that Eric is probably right that he would feel that way, but she would also ask him what he means when he says he couldn’t handle it.

“Usually when kids say they can’t handle it, they just mean that it would be difficult to deal with,” she explains. “But they will get through it because they have to and they have gotten through difficult things before.”

To help Eric put his fear and anxiety into perspective, Elsaesser would also use Socratic questioning and ask him, “If your parents did fall, then what would happen?” or “If others helped you, what would happen?” By taking this approach, Eric may respond to the scenario by saying, “Yeah, it has never happened before, but they always walk on the sidewalk in our neighborhood so a neighbor could see them.”

“Lots of times worries feel very big and overwhelming, but once we say them out loud and question them, we see they are not likely to occur or are that difficult to manage,” Elsaesser says.

Setting children up for success

With treatment, children can learn to feel more at ease with themselves and the world around them. Helping clients build a strong social network outside their family and school is pivotal in helping them learn how to better manage anxious thoughts and emotions, Jozwicki says.

“For those presenting with anxiety disorders, a strong social network may also serve as another outlet for them to share their concerns with their peers,” she explains. “Social networks, such as friendships, allow children to feel safe, which is the opposite of feeling anxiety.”

Elsaesser says when children learn what anxiety is, how it shows up in their bodies and what skills they can use to manage their anxious thoughts and behaviors, it sets them up for success in handling anxiety throughout their lifetime.

Pitman agrees. “When children can recognize what is happening in their body and build new neural pathways that take them to deep breathing, calm problem-solving skills and regulated ability to think, they can become adults who are no longer consumed with anxiety,” she says. “And instead, they can live peacefully and enjoy their life, no matter what comes their way.”


Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Confidentiality comes first: Navigating parent involvement with minor clients

By Bethany Bray October 28, 2022

What is said between a counselor and an individual client is confidential, even when the client is a minor. But parents often want to be kept in the loop about their child’s progress in therapy. This can put the counselor in a tricky situation, especially when the parents want to control or influence the counseling process.

The only scenario in which counselor-client confidentiality can be broken is in situations that necessitate protecting the client or others “from serious and foreseeable harm,” such as suicidal intent. (For more on this, see Standard B.2.a. of the 2014 ACA Code of Ethics.)

Marcy Adams Sznewajs, a licensed professional counselor (LPC) who often works with teenage and young adult clients at her group therapy practice in Beverly Hills, Michigan, says she empathizes with parents who ask about what she’s covering in counseling sessions with their child. However, she finds it helpful — and necessary — to offer a firm explanation of counselor-client confidentiality whenever she begins counseling a young client.

Sznewajs says that she emphasizes to parents that she will let them know if their child discloses anything that will put the child in danger. She also makes it clear to both parties that she will only invite parents into the counseling sessions if the young client grants permission.

This conversation is often not what the parents want to hear, Sznewajs admits, but it is important because it spells out the boundaries of what the counselor is obligated to tell the parents and reassures the client that their privacy will be respected.

Sznewajs stresses to families that they all must trust the process for her work to be effective.

“It’s important for the teenager to trust an adult with these difficult thoughts and feelings, and legally and ethically I have to keep it confidential,” says Sznewajs. “I’d be doing my client a huge disservice [if I disclosed session details to the parents]. That’s not only unethical, it’s damaging — and what does it teach the kid? That this person that you’re supposed to trust, you can’t.”

The feelings behind the questions

Parents’ concerns and questions about the work their child is doing in therapy are often rooted in fear, says Martina Moore, a licensed professional clinical counselor supervisor with a mediation and counseling practice in Euclid, Ohio. Not only do parents worry that the challenging behaviors that caused their child to seek counseling, such as rule breaking, isolation, defiance or problems at school, will have negative long-term outcomes in the child’s life, but they might also feel these issues are a reflection of their parenting abilities.

“Parents sometimes have such anxiety about their children it’s [gotten] to the point where they are increasing their child’s anxiety,” notes Moore, president of the International Association of Marriage and Family Counselors, a division of the American Counseling Association.

Although Moore makes a point to validate these fears with parents, she also emphasizes that it’s good for the child to grow and build autonomy through counseling on their own. She applauds parents for seeking help while explaining that she needs the freedom to work with the child alone for the counseling process to work.

“I also spend time with parents to dig into what their fear is. They’ve come to counseling [with their child], so they must believe that there is benefit in this process,” Moore says. She emphasizes to parents that they need to trust the process. “I spend a lot of time with parents getting their buy-in,” she notes.

In addition to fear, parents may also struggle with strong feelings of shame for having a child who is engaging in risky behavior and failing to thrive.

Le’Ann Solmonson, an LPC in Texas who has extensive experience working with children and adolescents, says she makes a point to acknowledge and normalize parents’ feelings of vulnerability and worry. If appropriate, Solmonson says she will sometimes disclose that she’s experienced similar feelings when her adult children sought therapy.

“No parent is perfect, and you worry over feeling like they are talking [in therapy] about what you’ve done wrong,” says Solmonson, the immediate past president of the Association for Child and Adolescent Counseling, a division of ACA. “It’s a very vulnerable thing to have your child go to counseling. You can’t help but feel that it’s a reflection on you as a parent and feeds into fears that you’re ‘screwing your kids up.’”

Navigating the balance

Counselors often need to get creative and act diplomatically to keep parents in the loop while maintaining young clients’ confidentiality and trust.

When parents insist on being involved in their child’s counseling, Moore negotiates with both the parents and client to find a plan that they all agree on while staying within ethical boundaries.

This was the case for a teenage client Moore once counseled who had substance use disorder. The parents were worried about their child and wanted to be involved in the counseling process. Moore facilitated a discussion and, eventually, they all came to an agreement that Moore would work with the teen alone but would let the parents know whenever the client had a relapse or break in recovery, she says.

Keeping lines of communication open and having regular check-ins with parents is beneficial to the counseling process with young clients, Solmonson notes. She often prompts child or adolescent clients to identify one small thing they are comfortable sharing with their parents at the conclusion of each counseling session, such a breathing technique they learned or new words they discovered to describe their emotions. This keeps the parents in the loop while ensuring that the client maintains control over the process.

When parents are left completely in the dark about their child’s work in counseling, it can exacerbate worry, cause them to “fear the worst” and catastrophize about what the child might be saying, Solmonson adds.

Sznewajs notes that talking with young clients about keeping their parents updated also provides the opportunity to check in with the client and ask what they feel is going well. She sometimes begins by asking the client how they feel things are going in counseling and transitions to what (or if) they would want her to share with their parents about their progress.

Disclosure of life-threatening behavior

When a young client is engaging in risk-taking behaviors that are life threatening (i.e., suicidal actions, self-harm), ethically, parents need to be brought into the conversation, says Hayle Fisher, a licensed professional clinical counselor and director of adolescent services at a behavioral mental health provider in Mentor, Ohio. While this is crucial to do, it can also impair the therapeutic relationship with the teen, she adds.

Fisher finds the vignettes in the 2016 British Journal of Psychiatry article “‘Shhh! Please don’t tell…’ Confidentiality in child and adolescent mental health” particularly helpful for examples on navigating these conversations. She keeps the following notes for herself, drawn from that article, for situations when she must disclose a young client’s harmful behavior:

  • Tell the client what you (the counselor) are planning on disclosing to the parents, with an emphasis on the full context of why you need to. Ask for their feedback on how they might like to edit what you plan to say.
  • Talk through the potential benefits and costs of disclosing to the parents. Ask the client how they feel about the disclosure and consider their views as you move forward.
  • Validate any fears the client may have about the disclosure, such as losing access to resources and freedoms, feeling blamed or ashamed, or being concerned that the police or social services will become involved.

To maintain trust and a therapeutic alliance with young clients, Fisher emphasizes that it’s important for a counselor to give the client as much control as possible over how this communication will occur. If the disclosure happens during an in-person session and the parents are nearby, she gives the client the choice to either stay in the room or step out and wait in the lobby when she invites the parent(s) in to tell them.

Fisher also gives young clients the option to tell their parents before she does. However, this is only appropriate if the client’s risk of harm is not imminent, Fisher stresses. In this scenario, she tells the client that she will call at a certain time the following day to speak with their parents, check in and provide support for the parents and client.

“This option is especially powerful,” Fisher explains, because it “reinforces the adolescent taking accountability for their actions, increases communication skills and fosters independence in the situation so they are not dependent on the counselor for navigating conflicts with their parents.”

Sznewajs also takes a collaborative approach when it’s necessary to break confidentiality to inform a client’s parent or guardian about harmful behavior or intent. She says she tries to take the client’s feelings into consideration while modeling firm boundaries.

Although not having the conversation with the parents isn’t an option, client can choose how and when it happens, Sznewajs explains. She offers to involve the parents in person, call them on the phone, do a video chat during the counseling session or wait until after the session ends.

Sznewajs says she explains to young clients: “I want to make sure you stay safe, so we have to bring your parents into this conversation.” She adds that she tries to “do it in a collaborative way, even when it [the situation] is dire.”





Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Taking a clinical selfie

By Bethany Bray October 25, 2022

“But first, let me take a selfie.”

This phrase, which was first popularized in The Chainsmokers’ 2014 breakout hit song “#Selfie,” has become a common saying in today’s culture — and one that is sometimes used to satirize younger generations who can’t seem to experience something without documenting it with a self-portrait.

On the surface, the act of taking a selfie can seem shallow or self-promotional. But Amanda Winburn and Amy King, both counselor educators who have a background as a school counselor, say that when used intentionally and in a structured way, selfies can become a therapeutic tool and a way to spark self-reflection, engagement and connection with younger clients.

“We know that children are engaged in” taking selfies, says Winburn, a licensed school counselor, licensed professional counselor and registered play therapist. “So why not take the positive attributes of this practice and expand upon it” in counseling?

Selfies in session

Winburn and King, who have presented on the therapeutic power of selfies at conferences of the American Counseling Association and the American School Counselor Association, have used selfie activities as a therapeutic intervention in individual and group counseling settings.

“This is just one more way we could give children and adolescents an opportunity to express themselves and narrate their story,” says Winburn, an associate professor of counselor education at the University of Mississippi. “We try and incorporate [clients’] worlds in our work, and selfies are an everyday part of our world and everyday part of expression for children, adolescents and adults. It really is the new self-portrait.”

However, Winburn and King stress two important caveats to this work:

  1. Practitioners should take care to ensure that any selfies captured in sessions are not taken with a device that is connected to the internet (i.e., not the client’s personal cellphone) so the images cannot be shared or used in a nontherapeutic context.
  2. Practitioners must obtain consent from a parent or guardian to capture the image of any client under the age of 18.

King, a certified school counselor and provisionally licensed professional counselor in private practice in Mississippi, uses a tablet computer that does not have internet access to allow students and clients to take selfies. She prints the selfie images and keeps them in a client’s file to refer to during sessions and deletes the images from the device. The tablet and client files are kept in a locked cabinet in her office when not in use, she explains.

Tapping into self-expression and boosting empathy

Having young clients take selfies during counseling sessions can serve as a visual and relatable way for them to track their progress in therapy, Winburn and King suggest.

Selfies can document physical aspects of improvement and growth in ways that a client may not notice without a visual record, such as smiling or holding their head up more, sitting tall and appearing more confident, Winburn explains.

When she was a school counselor, King once used selfies to help a student who was struggling with self-confidence. The student kept the printed selfies that she took in counseling sessions in a journal, to which she added notes and drawings. When King and the client talked about her therapeutic progress and looked through the selfies together, the young client was able to recognize that she looked happier and more confident in her progression of photos throughout the year.

She was able to note that she had gotten taller and that her smile was brighter. “She was glowing because she was looking at herself in a really positive way and reflecting about that,” King recalls.

King, a lecturer in counselor education and supervision at Boise State University, finds that students love to look back at their progress in counseling, and by using selfies, young clients can visualize that progression of moving away from having a tough time to having a better outlook on their situation or life.

In addition to strengthening expression and self-confidence, using selfies in this way also provides an opportunity for counselors to explore and process clients’ feelings of self-doubt or self-criticism, Winburn says. In therapy, selfies can be a visual portrait of a client’s narrative and a discussion starter for work that increases self-awareness and emotion recognition.

Winburn advises counselors to ask clients questions to understand the motivations behind their self-expressions and explore if they are trying to portray themselves differently than they really are. For example, she says clinicians can ask, “How does seeing that image make you feel?” or “What makes you feel that way?”

Winburn asks her counseling students at the University of Mississippi to take a selfie at the beginning and end of their day for an entire week. She tells her students, “It’s a way to step out of your comfort zone and process how you were feeling [that week] and how you portray yourself.” Then they reflect together in class on the story their selfies tell, which can be quite eye-opening, Winburn says.

King also used selfies in group counseling with second grade girls during her time as a school counselor. The group’s focus was on building confidence, communication, friend making and social skills. Learning to give and receive positive affirmations — to oneself and others — was an important component of this group work, King notes.

King, assisted by graduate counseling interns, had each group participant take a selfie with a school-issued tablet computer. The student would first look at the selfie themselves and then share it with the group. This activity allowed participants to open up and talk about the feelings their selfie elicited and, in turn, prompt group members to offer positive feedback.

It was a powerful experience that boosted the second graders’ empathy, reflection and listening skills and their ability to consider others’ perspectives, King says. The students would listen, connect and make comments such as “your eyes are really sparkling in that one,” she recalls.

After the group had been meeting for a little while, teachers and recess monitors at King’s school began to report that the students who were in her counseling group started to have more positive interactions during recess, she says.

Using selfies in counseling can help children actively learn and foster positive feelings about themselves as well as learn about individual and cultural differences in group settings, King notes.

“There’s no right or wrong way to make a selfie,” she adds.

Keeping an open mind

King and Winburn acknowledge that counselors can sometimes be skeptical of using technology in sessions, especially mediums such as selfies that can have negative connotations. However, they feel that when used in an ethical and appropriate way, selfies can strengthen trust and the therapeutic alliance with young clients.

It can also be a way to model that technology can be used in a positive way, to build each other up, King adds.

“Make sure you’re using safeguards to keeps clients safe, but try it [using selfies], embrace it and be open to it,” Winburn urges. “Especially with adolescents, counselors need to be playfully engaged and aware of where they are. This is an active way of embracing the world that they live in and meeting them where they are.”



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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Building resilience in children after a pandemic

By Celine Cluff October 13, 2022

A lot has changed for adults and children since the onset of the COVID-19 pandemic. People’s social and work lives have been turned upside down. Children had to unlearn the behavior to touch and explore the world around them, and with an overall uptick in anxiety, they have also had to learn to cope with increased stress levels in their environments. The toll that this has taken on youth remains to be explored.

Psychological resilience represents the ability to mentally or emotionally cope with a crisis or to return to the original precrisis status. According to the research of Michael Ungar, founder and director of the Resilience Research Centre at Dalhousie University, and Kristin Hadfield, an assistant professor of psychology at the Trinity College Dublin, factors that improve a young person’s life change depending on whether they live in a community that is stable and safe or one that presents them with a challenging environment. This means that we have to pay attention to a child’s environment to understand what factors help them build resilience. COVID has certainly had a negative effect on peoples’ environments, and it may have even caused surroundings that were stable and safe to turn into ones that are not.

With the implementation of four simple steps, the connection and trust between children and caregivers can be strengthened, which, in turn, can lead to the mitigation of some of that angst still lingering from the pandemic.

Step 1: Have a conversation during a meal. Dinners are a great proxy for connecting. At a minimum, sharing a meal serves as a way to catch up and reconnect. Admittedly, dinners with young children don’t tend to last long, but often a quick check-in will suffice if done regularly as a part of a daily routine. For example, a family could set an egg timer for ten minutes of “family time” and then take turns talking about their “rose and thorn” of the day; the rose is something positive that happened that day, and the thorn represents something less desirable that may have occurred. This exercise works to strengthen the interpersonal connections between family members and helps them stay on top of things that require attention that may otherwise slip through the cracks.

Step 2: Teach choice-based behavior. Caregivers can boost confidence levels in children by inviting them to practice autonomy. A simply way to do this is for a caregiver to offer the child options when they want them to do their chores or help around the house. For example, if the caregiver wants the child to help with dinner, they could say, “It is your turn to set the table for dinner. You can do this now, or you can choose to clear the table after dinner instead but you’ll have to load the dishwasher too.” Caregivers can also discuss and acknowledge how important their contribution is. Praising the child for accomplishing the task and letting them know that their help is valued delivers a confidence boost and strengthens the connection to their caregiver. After all, everyone appreciates being valued for their efforts!

Step 3: Teach initiative taking. Initiative taking — completing a task or chore without being prompted to do so — is a skill that can be taught. The most effective way to encourage this independent behavior is to model it, encourage it through positive reinforcement and let it happen organically. Sometimes this means biting one’s tongue instead of telling the child to stop doing what they are doing (if what they are doing is safe). Initiative taking is a skill that can be developed in early childhood and will serve children well into their adult years. It promotes a sense of self-worth by making children feel capable to make decisions and execute tasks. Letting children explore what they are capable of in a safe environment can boost confidence and encourage independent behavior down the road.

Step 4: Be present. Children have a universal talent for demanding attention. Sometimes, it is possible to give them the attention they crave and other times it’s not. Here’s a common scenario: A child demands attention when their caregiver is in the middle of something that requires their neurons to fire at full capacity. Although it may seem daunting, taking one minute out of their busy work schedule to make eye contact with the child and hear them speak will not negatively affect productivity levels or work outcomes. But what it will do is show the child that they are valued and heard, which boosts their confidence. In addition, modeling good listening skills will strengthen the caregiver-child bond and will help to ensure continuous respectful exchanges in future interactions.


In summary, a resilient child will have at least one continuous, resilient interpersonal relationship with a parent, caregiver, close relative or even friend. Nurturing these relationships plays a pivotal role in the maturation of a child’s psychosocial development. The four steps mentioned previously are suggestions on how to nurture these connections. Research from the realm of positive psychology continues to underscore the mental health benefits of having fulfilling interpersonal relationships. According to Mark Holder, a psychological researcher and former associate professor at the University of British Columbia, nurturing interpersonal relationships also contributes to people’s happiness, and it is the quality, not the quantity, of the relationships that brings people the most joy.

The concept of increasing happiness levels by nurturing interpersonal relationships also applies when children interact with other children. It is important to let children engage with each other on their own terms (interfering only if necessary), enjoy outdoor playtime, act out different scenarios with peers (e.g., playing cops and robbers, which is a variation of tag) or simply enjoy the company of like-minded youth. Children’s social and emotional repertoires are developed during these early years. Although extracurricular activities are also valuable, they cannot replace the social/interpersonal exchange in early childhood development. It is important to keep in mind the need for both when raising resilient kids.

In their research, Ungar and Hadfield emphasize people’s social ecologies (or preservation thereof) when it comes to their development and level of resilience during times of crisis. Because creating a stable and safe environment plays a pivotal role in laying the groundwork for this development, staying open minded about ways to parent during times of crisis is also important. A simple exchange about what the caregiver’s day was like or how they are feeling (happy, sad, etc.) will often go a long way. It is always a pleasant surprise to learn how much children can give in return if they are shown that adults are vulnerable too.



Celine Cluff

Celine Cluff is a registered clinical counselor practicing in Kelowna, British Columbia, Canada. She holds a master’s degree in psychoanalytic studies from Middlesex University in London and recently completed her doctorate in psychology at Adler University in Chicago. Her private practice focuses on family therapy, couples therapy and parenting challenges. Contact her at celine.cluff@yahoo.com.





Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.