Acceptability and Utility of Telehealth Group Services for Youth Problematic Sexual Behaviors in Rural Communities: Caregiver,Youth,and Clinician Insights

Study Design

In the present study, we conducted focus groups in North Dakota with caregivers (two focus groups, n = 8), youth (two focus groups, n = 8), and clinicians (one focus group, n = 6). All participants included in the study were actively participating in telehealth PSB-CBT group treatment services. Semi-structured focus group interview guides were designed to obtain in-depth information about participants’ perceptions and experiences with group-based mental health PSB services delivered via a telehealth platform.

Participants

All participants were recruited through Child Advocacy Centers (CACs) in North Dakota. These agencies were identified as ideal candidates for the study due to North Dakota CAC’s extensive history of using telehealth as the primary delivery system for EBTs. All participants were actively engaged in group PSB-CBT telehealth services at the time of the focus groups.

Age of youth who participated in the focus group(s) ranged from 8 to 15 years old (M = 11.75, SD = 2.32); all youth identified as male. Youth race/ethnicity was white (62.5%), Native American (12.5%), Hispanic heritage (12.5%), and one youth preferred not to answer (12.5%). Caregivers in the focus groups were predominantly female (62.5%) and were married or in a long-term partnership (75%). All families had been referred to CACs for PSB treatment. Clinicians providing PSB-CBT group services via telehealth were also recruited for the study. Majority of clinicians reported having a Master’s degree (66.7%) and two participants were clinical interns. All clinicians received specialized training in providing telehealth before conducting the PSB-CBT telehealth group; two-thirds (66.7%) of participants had less than a year of experience with telehealth for mental health services.

Measures

Procedures

The University’s Institutional Review Board approved all procedures before implementation of the study. The CACs leadership reviewed and approved all procedures, deferring to the University’s IRB as they did not have an independent IRB established.

Focus Group Procedures

Caregiver and youth participants were recruited through flyers distributed by clinical personnel to families actively participating in group telehealth services at North Dakota CACs. The flyer indicated that the project was recruiting caregivers and youth to share their experiences with telehealth for treatment. If interested in participating, each family was invited to attend their respective focus groups. At the onset of each focus group, the researchers reviewed the purpose, participation, and confidentiality, including that their individual responses would not be disclosed to their respective agencies. Electronic documentation of consent and assent was completed via secure links using the REDCap platform. After caregivers’ consent and the youth’s assent were established, a short demographic form was completed. The caregivers, youth, and clinicians met separately in each focus group, led by two teams of researchers. Each focus group lasted approximately 1 hour on a HIPAA-compliant platform (i.e., Zoom), which was recorded and transcribed. Each transcript was downloaded from the Zoom platform. Two research team members reviewed each transcript while observing the recordings to ensure each transcript captured the discussion accurately.

Barriers: Internal, External, and Impact of Rural Culture and Community Characteristics

Participants across all three reporter types (youth, caregiver, and clinician) emphasized experiencing or expressing feelings of stigma/shame and taboo nature of PSB, as significant barriers when families initially engage in services. For example, one clinician shared, “Even in the context of PSB or like sexual abuse, it’s just so taboo. A lot of people don’t want to talk about it. And there’s that stigma against the taboo things” All participant types identified families feeling guarded at the onset of services, noting that in rural communities, discussing and showing emotions is not acceptable. One caregiver stated, “You just hide it. That’s the way I was raised… You hide your feelings, like you’re fine… that’s how I was raised.” This was echoed by a youth “Never talk about it, never anything, just hide it. That’s the way I was raised.”

Interestingly, caregivers and clinicians both highlighted perceptions of power dynamics and the family’s previous experiences within the rural communities and service agencies (e.g., law enforcement, child protective services, juvenile services) as barriers to service engagement. Families receiving PSB services are often referred to or even mandated by local and state agencies. Caregivers and clinicians noted that poor interactions with agency systems before beginning services can cause families to enter therapy with negative expectations and an initial lack of genuine internal motivation and commitment. One clinician noted, “Sometimes I think caregivers are angry with other systems…so [caregivers] being let down by other systems creates barriers or challenges.” Negative past experiences in therapy also hinder initial engagement in mental health treatment, for example, one caregiver noted, “I’ve also had very horrible… horrible experiences with therapy. So…I’m okay with him doing it…But you know, I also am scared of it.”

Among the barriers expressed, unique themes emerged specific to rural communities of limited resources, culture (e.g., everyone knows each other, family and religious values), and the impact of multigenerational/historical trauma. Unsurprisingly, lack of trained and available providers with specialized training to address PSB was endorsed by the caregivers and clinicians. A clinician noted, “Another barrier is a lack of trained providers in our area, or clinicians to do group [therapy]. So training more people, I think, could overcome a lot of barriers as well.” Participants reported inadequate internet access as a common barrier in rural areas. Perhaps the most illuminating point identified by all groups was the lack of privacy and confidentiality in rural communities. One clinician shared, “Small communities operate like they kind of feel like they’re always knowing what’s up and are the talk of the town… like everyone knows everyone and everything about everyone sometimes.” One youth shared, “It kind of feels weird, you just met these people and you can’t really trust them… you don’t really want to share any private information with them…they could start sharing with other people that could start being posted all over the world.” Participants also noted strong religious and unique cultural values as factors impacting engagement in their rural communities. One clinician shared, “Culture and religion can affect treatment. Sometimes you have clients who don’t want to open up…They [youth] say in my family it’s not okay to cry, we don’t talk about our feelings.” Multi-generational trauma, particularly related to sexual abuse, was reported to influence pre-treatment perceptions. “I grew up in a very abusive, physically abusive, mentally abusive home… and my child went through something similar, so I would rather him get through it [treatment] and work through it.” Many families must navigate requirements and expectations across multiple agencies (e.g., juvenile probation) which can cause the family unit to be in crisis. Both caregivers and clinicians both reflected this sense of crisis as a significant barrier to active participation.

Unaddressed basic needs and lack of community support (e.g., extended family, neighbors) who could provide assistance (e.g., childcare during services) caused significant strain for many participants. “Supervision of childcare, especially if there is not a lot of natural supports in the home or outside the home or community, even… it can be challenging [for families],” one clinician shared.

Barriers to In-Person Services Among Rural Communities

Participants identified multiple barriers they would face if only in-person services were available, including time, transportation, location, and costs. Most notable among the groups was the time needed to travel from their communities to agencies for in-person services. Long commutes were discussed, particularly their added stress on caregiver work responsibilities and family finances. When asked how telehealth impacted their commute, one caregiver shared,

“…where I live [town] is 3 hours from here.” Another caregiver noted, “The time zone change, if it’s four o’clock down that way [CAC location], I would have to leave at one o’clock from my house to go over that way.”

Telehealth Benefits for Enhancing Engagement and Overcoming Barriers in Rural Areas

All participant groups shared the ability to be seen via telehealth overcame numerous logistical barriers, such as transportation, time to and from appointments, and childcare burdens commonly reported as in-person barriers. Beyond logistics, all groups described a sense of safety from participating in services from home. Telehealth was frequently described as promoting a “safe space” and enhancing a sense of privacy when discussing uncomfortable topics in both caregiver and youth groups. One caregiver noted, “You’re not comfortable. You’re already in that tense, tight kind of feeling when you walk in [in-person services], and then you don’t want to say the wrong thing while you’re in their office, you know…. yeah, I feel like I’m more me while I’m home.” One youth shared, “What I like about [telehealth] is I don’t have to be in person ‘cause I get nervous sometimes [discussing PSB].” A clinician emphasized privacy, stating,

“Telehealth is nice because it is discreet, more discreet than going into an office or having to take off two hours of school or work for travel and people asking where they go every week.”

Barriers to Engagement Among Rural Participants in Telehealth Group Services

Telehealth was not without barriers. Participants reported an initial hesitancy to use telehealth for treatment or a lack of technology literacy in rural communities as barriers to effective engagement in telehealth at the onset of services. One caregiver stated, “I have the computer skills of a wet paper towel. So you know, getting things turned on… is difficult. But it is worth it, and I mean anything worth doing generally is difficult.”

Per PSB-CBT treatment requirements, caregivers and youth must have separate devices and be in separate rooms to participate in group services. If the program did not have a technology loaner program, access to necessary devices and privacy concerns were noted as barriers across all participant types. Prior misconceptions about telehealth treatment were also highlighted. One caregiver shared, “Before I found out that this was all telehealth, I was very against it. I didn’t think telehealth would actually be meaningful.”

Considerations of the length of the group and the developmental appropriateness of telehealth were expressed. A caregiver shared, “It’s more about my child’s ability to sit still and pay attention for that long.” Clinicians highlighted, “One thing we discussed recently that makes doing therapy on Zoom challenging in group is we have a lot of kiddos with ADHD, some with Autism diagnosis, and it’s challenging to get them engaged and sit still long enough to actually be able to absorb the material during session.”

Engagement Strategies to Overcome Barriers for Rural Families

Themes on strategies to facilitate understanding and engagement in telehealth services were notable. All participant types shared the importance of engagement strategies and dedicating time to the family before initiating group services. Topics for this one-on-one time with the families included orienting to therapy, orientation to the technology, case management, and resource provision. Due to the sensitive nature of the referral, many emphasized the need for time to develop relationships, validation, genuineness, and empathy, and displaying respect in initial interactions.

Implementation of a technology orientation, described as a “tele-orientation,” was a critical strategy for new families. Creating a tech-loaner program for families lacking internet-capable devices was noted as a significant burden lifted from caregivers’ many responsibilities. Alongside assessing for device and internet access, implementing a screener addressing logistical barriers for the family was recommended to identify potential barriers to service engagement. One clinician shared, “We go over the treatment of what’s expected… We review when the group is, how long, a lot of logistical things…and then for people who have never done telehealth therapy, it [orientation] allows them to log in with less people.” Additionally, it was noted that clinicians must evaluate the youth’s electronic or online sexual behavior (EOSB) histories, provide education on equipment supervision and rules, and then use devices approved and monitored by the treatment agency to ensure safe use. A clinician noted, “Being able to provide them [families] with technology, especially for PSB groups. You worry that they’ll be on other sites and maybe their PSB involves technology… so being able to provide them with safe technology seems to be helpful [in reducing barriers].”

Outside direct work with families, clinicians reflected that misconceptions and myths regarding PSBs and treatment outcomes held by multidisciplinary team (MDT) members (e.g., juvenile justice professionals, law enforcement, pediatricians, social workers) hindered families’ motivation to engage in treatment. One clinician shared, “I think that’s a lot of the time, like however treatment was presented to the family, then it’s already setting us up for failure sometimes. If we take the time and educate our team members (MDT members) on what the treatment is and what it should look like, and what they should be saying to families…that will overcome that barrier.” Education of agency partners in the community about PSB in youth was recommended.

Dedicated time for one-on-one sessions with families and clinicians outside of the group was reported as important for engagement. One caregiver noted, “The people, the counselors themselves, have been really…great. They stay after the group to talk privately, or if we need assistance or anything…It’s been really nice that they’ve made themselves available for any help.” Families may come into treatment with previous negative experiences, which can be misconstrued as defensive or disengaged. One clinician reflected, “as [clinician participant] was saying about sometimes clients coming off as defensive, I think sometimes they’re [families] new to this process right? Sometimes they’ve never done therapy before, they don’t know what to expect. I think it’s very important starting off by validating those feelings and addressing those feelings of being uncomfortable.”

Setting expectations and treatment structure for telehealth groups, such as setting rules similar to in-person services (e.g., being in a private space), limiting distractions (e.g., using a space with no TV), and incorporating behavior charts was noted as important. The youth participants had varied views of distractions during telehealth. One youth reported finding telehealth helpful because it reduces distractions, while another reported that some youth take advantage of the platform’s special features, which can be distracting. Caregivers and youth shared that incorporating interactive activities (e.g., games, videos) and visual materials during the telehealth sessions enhanced engagement. Implementation of group activities to achieve therapeutic impact and to avoid an atmosphere of a “class” was noted. Provision of “Teleboxes” (mailed boxes that include supplies for therapy, including workbooks of handouts, headphones, fidgets, reinforcers) was identified as extremely helpful for engaging families and providing a similar experience to in-person services.

Lastly, participants noted privacy and confidentiality check-ins and rule reviews facilitated a sense of safety and promoted understanding requirements for therapy (e.g., privacy, focused attention). Some caregivers were noted to initially not understand telehealth sessions “like almost like it isn’t always treated like it’s a separate appointment, … Like a phone call during a break at work.” Setting limits and expectations and reviewing group etiquette were noted as important to keep the group focused on therapeutic activities. Youth voice noted the importance of pacing and not getting stuck on one topic. Check-ins with caregivers to praise youth progress and dedicated time for family sessions were highlighted as important factors that facilitate stronger family connections.

Logistical Strategies for Clinicians Utilizing Telehealth in Rural Communities

Clinicians shared lessons learned and strategies they believe make telehealth group services successful. A “pre-planning” stage was recommended before launching the telehealth clinical program to review and select a telehealth platform that has appropriate control settings, chat functions, and to educate all clinicians on how to operate it. Flexibility and having a co-facilitator to manage children with behavior problems and a team member who can troubleshoot any technical issues were viewed as critical for success and maintaining the flow of the group session.

Benefits of Telehealth Modality When Providing EBT Services for PSB

Consistently, clinicians, caregivers, and youths noted that the most impactful aspect of participating in virtual group therapy was hearing and learning from others dealing with similar sensitive issues. Caregivers and youth reported feeling less isolation, shame, and judgment from their group members and a new sense of community, a sense echoed by clinicians. One youth stated, “I thought I was going to be judged and all that but in reality, we are all there for something similar. Nobody’s going to judge you.” A caregiver shared, “Coming into [therapy], I was a little worried the things I was going through were just me, but…knowing that other people are going through similar things with their children definitely helps. It’s kind of an ease of mind, letting me know that there’s things we can work through and get past and we can overcome.” A unique theme identified was related to the open group format, and that having group members at different points in treatment inspired hope as members graduate from the treatment program. A caregiver shared, “Participation is key. If you don’t participate, you don’t get the full grasp of all of it… Before they [previous group members] graduated, they opened up to me about why they were there. I felt like that [participation] helped me be able to share with them.”

Caregivers and youth reported that being part of a group enhanced their ability to express feelings, manage their own/child’s coping, relationship skills, and that getting advice directly from group members. Creating friendships, feeling connected, and sharing advice among members was noted by multiple participants. When asked by the interviewer what makes discussing sensitive topics easier, a youth shared, “Cause I’m not alone.” Youth also reported that the group aspect enhanced accountability and a desire to maintain healthy sexual boundaries.

“There are other people that…have similar problems [PSB]. So I can give advice, and you can give them advice…It’s just stuff like, I'm not the only one with stuff like that [PSB].”

Limitations and Future Directions

This study represents an initial exploration of youth, caregiver, and clinician lived experiences with group telehealth to address PSB of youth. Characteristics of this specific sample must be considered when interpreting the findings. The youth participants in this study all identified as male. Although the vast majority of teenagers with PSB are male, females are not uncommon samples of 7–12-year-olds with PSB (Allen, 2023; Friedrich et al., 2001). Further, while the sample was representative of North Dakota’s population in terms of race and ethnicity, the lived experiences of Black, Asian, and other cultural groups require additional research. Further, all participants were involved in the same program, in North Dakota, and the groups included clinicians and family members who were relatively recent to the program. Follow up studies of additional populations can enrich understanding of themes that are both universal and unique to specific rural communities. Capturing the insights of families who were referred for services but failed to engage could elucidate additional barriers and notably is a particularly challenging population to engage in research. Additionally, the authors opted to utilize focus groups to facilitate the process of the members ability to express beliefs, perceptions, and recommendations in a manner that facilitates connections to ideas and deeper discussion (Onwuegbuzie et al., 2009). However, by not using an individual interview format, some unique messaging may have been missed, and future research would benefit from allowing individual time for each participant. Given the concerns raised about families’ previous experiences with agencies and services, expanding research on perspectives of key professionals in the rural communities (e.g., child protective services, law enforcement, schools) on telehealth and PSB is recommended.

Direct evaluation of outcomes of group telehealth services to address PSB of youth are needed. Similar programs of research examining telehealth outcomes for TF-CBT and PCIT (Comer et al., 2021; Nicasio et al., 2022; Ros-DeMarize et al., 2021) are quite promising for the impact of EBT through the telehealth modality. Treatment outcome research on group CBT for PSB of youth via telehealth is a critical next step, examining impact not only on future PSB, but also impact on co-occurring issues (e.g., trauma and general behavior problems) as well as vulnerability and protective factors (e.g., parental stress, support, and behavioral management skills). Assessment of PSB types should include electronic and online sexual behaviors and interpersonal in-person PSB (Allen et al., 2026). Testing telehealth strategies to facilitate engagement and impact with youth who have developmental or behavioral challenges, similar to work being conducted with TF-CBT is warranted (McDonnell et al., 2026).

Conclusions

In summary, telehealth group treatment for PSB of youth has great potential for preventing CSA across rural communities. Findings support telehealth to reduce barriers across internal, logistical, and clinical factors associated with rural areas. While promising, further research on telehealth implementation of PSB-CBT and similar programs is needed to examine engagement, barriers, and treatment outcomes with diverse and special populations.