Universal digital mental health interventions (DMHIs) aimed at promoting well-being and resilience in children and youth are associated with small improvements in some psychological outcomes, although the overall certainty of evidence is low, according to a systematic review and meta-analysis.

The study, which involved 16 meta-analyses across 57 studies and included 43,973 participants, found that hybrid interventions (which combined digital delivery with in-person engagement) had the most consistent benefits across the outcomes studied. N early half of the analyses had findings that were not statistically significant, however.

Because only a few analyses reached moderate certainty, the findings should be interpreted cautiously, noted senior author Rebecca Pillai Riddell, PhD, clinical psychologist and professor of psychology at York University in Toronto. The researchers also worked with Strong Minds, Strong Kids — Psychology Canada, a national charity that promotes children’s mental well-being through psychological science.

“Null findings in social and cognitive domains highlight the need to design interventions that directly target these areas,” the researchers wrote. “Rather than diminishing enthusiasm, these findings suggest that interventions in these domains may not yet be optimally designed or evaluated to detect more subtle developmental changes.”

The study was published online on July 27 in npj Digital Medicine.

Small Effect Sizes

Universal (also known as Tier 1) DMHIs are broadly aimed at mental health promotion and resilience at the population level, rather than at targeted treatment of diagnosed conditions. Such interventions are delivered through various modalities, including mobile applications, web-based programs, chatbots, and virtual sessions. To date, no review has focused specifically on universal DMHIs while also providing a quantitative synthesis across multiple psychological outcome domains, the authors noted.

The analysis included studies that assessed emotional, behavioral, social, and cognitive outcomes for children and youth (aged between 0 and 18 years) without a diagnosed mental health condition who were delivered DMHIs either fully virtually or in hybrid formats. The researchers examined whether delivery format and timing of assessment influenced results.

The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework, which considers factors including risk for bias, inconsistency, indirectness, and imprecision. The researchers did not formally assess publication bias because of the small number of studies in the individual analyses.

Among the measures used to assess the four domains were the Revised Children’s Manifest Anxiety Scale, the Child Behavior Checklist, the Strengths and Difficulties Questionnaire-Peer Relations Scale, and the Problem-Solving Inventory.

Across the 16 pooled analyses, the researchers found small effects in several emotional, behavioral, and social outcomes, particularly for hybrid interventions.

For emotional outcomes, significant effects were observed for hybrid interventions immediately after the intervention and at follow-up. But certainty was low to very low.

For behavioral outcomes, “significant effects were observed for both hybrid and virtual delivery at immediate post-intervention and for hybrid delivery at follow-up, which was supported by moderate certainty.”

For social outcomes, “significant effects were observed for hybrid delivery at immediate post-intervention and at follow-up, with the follow-up effect supported by moderate certainty.”

For cognitive outcomes, “overall, there is limited evidence that universal DMHIs consistently improve cognitive outcomes,” the researchers wrote. “However, findings for virtual delivery at follow-up suggest a potential benefit, although the certainty of evidence remains low.”

Real-World Contexts

Confidence in most findings was limited by methodologic weaknesses, including high or unclear risk for bias in many of the included studies, as well as inconsistency and imprecision, the researchers cautioned.

For example, among the 39 randomized controlled trials included, 20 (51.3%) had a high overall risk for bias, 11 (28.2%) had unclear risk, and only 8 (20.5%) were rated low risk. And among the 18 nonrandomized studies, 16 (89%) had serious overall risk for bias.

The authors also noted that most studies were conducted in high-income Western countries and that marginalized populations and younger children were underrepresented, limiting the generalizability of the findings.

“It’s clear that digital tools must be embraced but only if we implement them thoughtfully, equitably, and with real-world contexts in mind. We need to invest in research that includes the children most often left behind,” said Riddell.

“The near absence of parents and caregivers of children ages 0-4 years from the evidence highlights an important gap, since universal interventions for the youngest children are typically delivered through parents or caregivers,” the authors told Medscape News Canada. “Our hypothesis is that these tools will work best when cocreated strategies support parents’ and caregivers’ own mental health, not just their skills in supporting children.”

Mental health tools also must be acceptable to marginalized communities, they added. “That means codesigning tools with communities, addressing cultural stigma around mental health, and engaging community leaders to promote health, whether religious leaders, coaches, or family physicians.”

In addition, the physical, mental, and spiritual dimensions of health must be reinforced, they said. “Our meta-analysis points the same way: benefits held up best when digital tools were embedded in everyday settings like schools, not delivered as standalone mental health products.”

Training and Support Needed

Commenting on the findings for Medscape News Canada, Manuela Ferrari, PhD, associate professor of psychiatry at McGill University and researcher at the Douglas Hospital Research Centre, both in Montréal, said that the review makes a timely and important contribution. Ferrari did not participate in the research.

“While the findings provide encouraging evidence for the benefits of virtual and hybrid interventions, particularly for behavioral and cognitive outcomes, they also highlight a critical gap in the field: the lack of evidence from the very populations most likely to experience barriers to care and potentially benefit from accessible, scalable digital solutions,” she said. “The limited representation of equity-deserving groups is therefore not merely a methodologic limitation but also a significant equity concern.”

The positive findings for hybrid interventions are particularly noteworthy, said Ferrari. “Embedding digital tools within schools and community settings may provide the social support, guidance, and accountability often missing from fully virtual interventions. However, implementation should not assume that technology alone drives outcomes. The educators, facilitators, moderators, and community leaders delivering these interventions require appropriate training and support to bridge digital and cultural knowledge. Their ability to understand the social and cultural contexts of participants may be a key factor in fostering engagement, trust, and sustained benefits.”

Future implementation research “should focus not only on whether interventions work but also on whom they work for, under what conditions, and how they can be delivered in ways that advance equity rather than widen existing disparities,” she concluded.

The study was funded by the Jackman Foundation and York University.Riddell and Ferrari declared no relevant financial relationships.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.