Brightline is a company that offers a technology-enabled behavioral health solution designed for children (aged 18 months up to 18 years) and their families [21]. Brightline delivers self-guided content, coaching services, and virtual care through multidisciplinary care teams, family-focused support, and evidence-based care delivery geared toward helping children and their families across developmental stages. Commonly reported behavioral health needs by Brightline users include anxiety, depression, and disruptive behavior disorders.

The web-based survey was available on a landing page on the Brightline company website between October 2020 and November 2021 and provided an overview of the survey to participants (Multimedia Appendix 1). A link to the survey was shared on Brightline’s social media platforms, such as LinkedIn and Twitter, throughout the survey window. Other than being shared on social media and through the other avenues, participants were not actively recruited to participate in the survey. Moreover, Brightline membership was not required to access and complete the survey.

Anyone who visited the Brightline website during the study period could complete the survey. Participants were not compensated for completing the survey. There were no other eligibility criteria or exclusion criteria for participation. While this allowed our survey to be accessible to any interested participant, it also meant that a nonparent could complete the survey.

Participants voluntarily completed the anonymous, web-based survey. The survey took approximately 10 minutes to complete. Once participants submitted the survey, they received a summary of each of the 4 survey components (Multimedia Appendix 2). The participant could then choose to follow a link to resources and a guide to help facilitate a conversation with a pediatric behavioral health care provider (Multimedia Appendices 3 and 4).

The survey was designed from 3 standardized clinical instruments, focusing on psychological stress, family resilience, family connection, and preexisting behavioral health conditions. The survey was augmented by a set of questions about parental productivity and time spent managing children’s behavioral health, as well as questions related to the direct impacts of the COVID-19 pandemic and participant demographics (Multimedia Appendix 5). These instruments were selected because they aligned with previous research that identified both nonmodifiable and modifiable risk factors for children’s postdisaster mental health outcomes and well-being, such as mass disasters (eg, 9/11 attacks), natural disasters (eg, hurricanes), and previous epidemics [11-14]. Further, these instruments were selected because they do not evaluate for any clinical domains that would require Brightline to intervene in the case of high acuity needs.

This retrospective, cross-sectional study analyzed survey responses collected from participants (N=361) between October 2020 and November 2021. All statistical analyses were performed in R version 4.1.2 (R Foundation for Statistical Computing). Prior to analysis, all predictor variables underwent min-max normalization. Multivariable linear regression was used to characterize the associations among productivity interruptions, family stress, family connection, family resilience, and COVID-19–related exposure experiences. This linear regression was adjusted for household income and parental education level. Goodness of fit was performed for linear regressions.

This study protocol was approved by the Western Institutional Review Board and the Copernicus Group Institutional Review Board.

Participant demographics are presented in Table 1. The participants primarily had a White racial background, were married women who were highly educated, and reported high incomes.

The direct impact of COVID-19 on participants are presented in Table 2. Over 90% (341/361) of the participants reported neither they nor their spouse had been diagnosed with COVID-19. The responses to the question “I have experienced adverse financial consequences due to COVID-19” are also summarized in Table 2. A majority of participants (233/361, 65%) said they had not experienced financial consequences as a result of COVID-19.

The preexisting behavioral health needs of the participants’ children from the CSHCN screener, which is commonly used to evaluate whether a child already has behavioral health needs prior to evaluation, are presented in Table 3. Approximately 28% (102/361) were described as having an emotional, developmental, or behavioral problem for which he or she needs or gets treatment or counseling, and 21% (76/361) reported their child needing more medical care, mental health, or educational services than is usual for most children.

The responses for the item “Since Covid began, how much time (on average) are you spending managing your child or children’s behavioral health concerns (including their stress, anxiety, disruptive behaviors)?” are summarized in Table 4. Nearly 50% (155/361) of the participants reported spending between 2 and 4 hours per week managing their children’s behavioral health. The responses to the question “How much is your child’s behavioral health and well-being affecting your productivity and ability to work if you are currently employed?” are also summarized in Table 4. The majority of the participants (307/361, 85%) reported some impact on their productivity and ability to work.

The responses for the PROMIS measure are summarized in Table 5. The mean summed PROMIS raw score was 23.05. The scaled score is approximately 64.4, which indicates moderate pediatric stress reported at the time of the survey among the participants in our study.

The responses for the FRCI measures are summarized in Table 6. The mean summed FRI score was 1.03, indicating low family resilience among participants in our study. The mean summed FCI score was 2.3, indicating moderate family connection among the participants in our study.

In the multivariable model, there was a strong association between productivity loss and the time spent managing children’s behavioral health needs (β=.365; P<.001) as well as Stress Index scores (β=.213: P<.001) (Table 7). There was a weaker association between productivity loss and FCI scores (β=–.125; P=.053) (Table 7). COVID-19 diagnoses among parents and dependents, financial impact of COVID-19 on households, and family resilience were not associated with parents’ workplace productivity (Table 7).

Our findings show that parents spend a considerable amount of time managing their children’s behavioral health needs. Although we did not find that having a COVID-19 diagnosis among a household member or having a significant financial impact on the household from COVID-19 impacted productivity, this may have been due to the fact that our participants had low rates of COVID-19 infection and were relatively high-income earners. An important extension of this work would be to assess the association of COVID-19 diagnoses and financial consequences of the pandemic on workplace productivity among lower-income earners and those with significant COVID-19–associated illness.

In addition, we found that high pediatric stress and more time spent managing children’s behavioral health problems were associated with increased productivity losses for parents regardless of COVID-19–related experiences. While COVID-19 variables were used as predictors in our multivariable regression model, we discovered that COVID-19 exposure-related experiences did not have a significant effect on our outcome. Despite the lack of representation of families affected by COVID-19, we felt it was important to incorporate this variable in our model.

Our findings also showed that enhanced parent-child connection is inversely associated with the parents’ productivity loss, even amid adversity [33-35]. This finding is significant because there are known behavioral health interventions that can be mobilized to enhance parent-child connection where parents are trained to support the management of children’s behavioral health problems. Our results further support those of previous studies, which show that pediatric stress and family connection are good predictors of pediatric behavioral health outcomes [36-38].

As with all survey research, there are limits inherent to this research method. As the survey was completed anonymously and was internet-based, we were unable to control for the chance that a nonparent completed the survey. Moreover, the tool produced some basic pediatric behavioral health insights that were tailored to the users’ answers after completing the survey; therefore, the participants may have been encouraged to take the survey more than once in order to receive different answers. This means that the same participant could have taken the survey multiple times without us knowing. However, allowing for anonymity likely increased the response rate and participation.

In this exploratory study, the majority of respondents represented a well-educated, high-income, female population. Further, participants were only recruited using digital channels (eg, search engines, email, and social media), all of which can potentially limit the generalizability to other populations. The participants may have included parents searching on the web for information related to child behavioral health; therefore, their responses related to perceived child stress and family resilience might not reflect the general parent population. Future studies will share the survey through alternate venues to recruit more diverse participants.

In designing the survey, we did not include questions on the number, age, and gender of children, potentially limiting the ability to draw insights on the differences between children and adolescents across behavioral health needs and impact on stress, family resilience, and family connection. However, research has shown that having a higher number of children is positively associated with a higher level of psychological distress in families [39]. Additionally, the survey did not include questions from the Sickness Index Profile, which evaluates the effect of disease on physical and emotional functioning [40]. There is opportunity to further explore the impact of COVID-19 and other illnesses or stressors on children’s behavioral health needs.

Building on our preliminary findings, in future studies, we aim to learn more about the time spent and its impacts on the larger family unit. In this iteration of the survey, we asked parents about their time spent managing their child’s behavioral health concerns. What we received is an estimated snapshot. We are interested in developing questions and methods to ascertain changes in time spent to learn whether this is associated with differing productivity and stress levels. Further, this survey includes responses from parents and caregivers on their individual time spent managing their children’s behavioral health (independent of their partner). Collecting data on time spend on the household level would give us greater insight into the impact a child’s mental and behavioral health has on the family and measures of productivity more broadly. Lastly, when completing the survey, the participants received recommendations and tools to help support their children’s mental and behavioral health needs. In future studies, we aim to collect data on the use of these resources.

Our preliminary findings confirm that measures of increased psychological stress in children and lower family connection are associated with productivity loss regardless of COVID-19 diagnosis, financial consequences of COVID-19, education level, and income level. These results suggest a continued need for research on family-focused behavioral health benefits that address pediatric stress levels and that offer support to manage children’s behavioral health problems and improve parent-child connections. Surveys that integrate standardized and validated measures of known risk and protective factors for children’s postdisaster well-being and outcomes can be useful mental and behavioral health points of entry for parents. The feedback that participants receive after completing a survey, for example, can make parents or caregivers more aware of these factors and help them to facilitate conversations with health care professionals about their concerns. This is especially important during crises such as COVID-19, when families have limited access to face-to-face community indicators of well-being.