Family Engagement in a Digital Intervention Targeting Risk for Anxiety in Parent-Child Dyads: Mixed Methods Study

Digital health programs are increasingly important in the treatment and prevention of mental health problems in young children. However, suboptimal family engagement with a program may hamper its effectiveness. Family engagement in digital mental health programs is multifaceted and poorly understood, with ill-defined relationships among aspects of participation and program outcomes (ie, what constitutes effective engagement). Moreover, little is known about the barriers and facilitators to effectively engaging families at risk for anxiety, who may not be actively seeking treatment.

Making Mistakes is a novel, internet-based, cognitive behavioral preventive program for caregivers and their 5- to 7-year-old children, which aims to reduce the risk of anxiety by targeting family transmission of perfectionism or error sensitivity-that is, negative overreactivity to mistakes. This mixed methods study examined multiple facets of parent-and-child engagement in Making Mistakes, including adherence, cognitive and affective engagement, barriers, facilitators, and perceived outcomes associated with involvement.

A total of 87 dyads were included in a quantitative analysis of adherence to the program, including overall adherence and sustained engagement. Eighteen dyads completed qualitative interviews, which were subjected to a qualitative thematic analysis. Finally, a sample of Making Mistakes activity journals was qualitatively reviewed and synthesized.

Parent and child adherence were strongly positively correlated (r85=0.95). Dyads had low adherence to the weekly modules, which did not differ by intervention condition. Completion rates averaged 20%, with adherence declining over time. In contrast, qualitative data indicated high levels of investment in program content and topics, elucidated barriers and facilitators to program engagement, and highlighted numerous psychosocial benefits.

Engagement, operationalized as rote adherence to an intervention developer's criteria, may insufficiently capture the aspects of participation that are most meaningfully related to positive outcomes. Researchers and intervention developers should prioritize cognitive and affective aspects of engagement with program content, along with promoting and assessing behavioral engagement beyond adherence to program components. Making Mistakes shows promise as a low-cost, disseminable strategy to reduce intergenerational risk for anxiety. These findings have particular relevance for digital health programs focused on prevention, parent-child dyads, and anxiety and perfectionism.