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

Background: 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. Objective: 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. Methods: 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. Results: 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). Conclusions: 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.