Family-Focused Digital Mental Health Care for Oppositional Symptoms: A Retrospective Analysis of Pediatric and Caregiver Outcomes (Preprint)

BACKGROUND Oppositional symptoms are characterized by an angry or irritable mood and excessive defiance (e.g., arguing), negatively impacting the mental wellbeing of children and 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. OBJECTIVE The purpose of this study was to assess oppositional symptoms in children and adolescents (ages 6 to 17) participating in care with a family-centered DMHI. We aimed to: 1) examine baseline oppositional symptoms and their associations with child demographic and clinical characteristics (e.g., 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’ sleep, stress, and burnout. METHODS Retrospective analyses included 4817 child-caregiver pairs who participated in coaching and therapy with Bend Health Inc., a family-centered, pediatric DMHI. Monthly assessments at baseline and during care measured pediatric and caregiver MH symptoms. Baseline assessments were used to classify children and adolescents into groups: not significant, subclinical, and clinical oppositional symptoms. Pediatric characteristics, care type, and caregiver symptoms were compared between-groups. Linear mixed-effects models assessed oppositional symptoms over months in care and then tested whether oppositional symptoms at baseline and during care were associated with caregiver outcomes over time. RESULTS Baseline oppositional symptoms were not significant for 50.72% (2443/4817), sub-clinical for 26.49% (1276/4817), and clinical for 22.79% (1098/4817). More severe oppositional symptoms were associated with younger age (P<.001), non-female sex (P<.001), White race or ethnicity (P<.001), higher rates of MH diagnoses (e.g., attention-deficit hyperactivity disorder and oppositional defiant disorder; Ps<.001), and higher rates of co-occurring inattention, hyperactivity, depression, and sleep problems (Ps<.001). Odds of elevated caregiver symptoms increased with more severe oppositional symptoms (all Ps<.001). During care, oppositional symptoms improved for 88.71% (1132/1276) with subclinical symptoms and 93.72% (1029/1098) with clinical symptoms, with significant monthly reductions (P<.001). While more severe oppositional symptoms were associated with more severe caregiver sleep problems, stress, and burnout during care (Ps<.001), monthly improvements in caregiver symptoms were significantly larger for those whose child had larger monthly reductions in oppositional symptoms. CONCLUSIONS Family-centered DMHIs may effectively address child and adolescent oppositional symptoms, as well as co-occurring impairments in caregiver wellbeing. These findings highlight the broader, system-level impact of scalable DMHIs (like Bend) in addressing complex family MH needs. Future work should examine the long-term stability of these effects and evaluate opposition-specific care pathways within DMHIs.