Family-Focused Digital Mental Health Care for Pediatric Oppositional Symptoms and Caregiver Outcomes: Retrospective...

Oppositional symptoms in youth are characterized by an angry or irritable mood and excessive defiance (eg, arguing), negatively impacting the mental well-being of children, adolescents, and their caregivers. Pediatric digital mental health interventions (DMHIs) that approach care from a whole-family perspective may effectively address mental health (MH) symptoms in both pediatric participants and their caregivers, though this has not been explored in the context of oppositional symptoms.

The purpose of this study was to assess oppositional symptoms in children and adolescents (aged 6 to 17 years) participating in care within the real-world conditions of a family-centered DMHI. We aimed to (1) examine baseline oppositional severity and its associations with child demographic and clinical characteristics (eg, co-occurring MH symptoms), and caregiver symptoms; (2) evaluate demographic, clinical, and engagement factors associated with oppositional symptoms during care with the DMHI; and (3) determine whether changes in oppositional symptoms during care are associated with improvements in caregivers' stress, burnout, and sleep.

Retrospective analyses included 3781 child-caregiver pairs who participated in coaching and therapy with Bend Health Inc, a family-centered, pediatric DMHI. Assessments at baseline and monthly during care measured pediatric and caregiver symptoms. Children and adolescents were grouped by oppositional severity at baseline: not significant, subclinical, and clinical. Pediatric characteristics, care type, and caregiver symptoms were compared between groups. Linear mixed-effects models assessed oppositional symptoms over months and then tested whether oppositional severity and rate of symptom improvement were associated with caregiver outcomes over time.

Baseline oppositional symptoms were not significant for 51.55% (1949/3781), subclinical for 26.47% (1001/3781), and clinical for 21.98% (831/3781). More severe oppositional symptoms were associated with younger age (P<.001), nonfemale sex (P<.001), White race or ethnicity (P<.001), higher rates of MH diagnoses (all P<.001), and higher rates of co-occurring inattention, hyperactivity, depression, and sleep problems (all P<.001). Odds of elevated caregiver symptoms increased with more severe oppositional symptoms (all P<.001). At the end of care (final follow-up), oppositional symptoms improved for 73.93% (740/1001) with subclinical symptoms and 82.43% (685/831) with clinical symptoms. Symptom trajectories followed a logarithmic curve, with the greatest improvements in the first several months (P<.001). While more severe oppositional symptoms were associated with more severe caregiver stress, burnout, and sleep problems (all P<.001), monthly improvements in caregiver symptoms were significantly larger for those whose child improved more quickly (all P<.001).

Family-centered DMHIs may effectively address pediatric oppositional symptoms, as well as co-occurring impairments in caregiver well-being. These findings highlight the broader, system-level impact of scalable DMHIs (such as Bend) in addressing complex family MH needs. Future work should examine these effects in the long term and evaluate opposition-specific care pathways within DMHIs.