Client feedback in psychological therapy for children and adolescents with mental health problems

Why is this review important?

Systematic feedback from clients to psychotherapists may improve outcomes of psychological therapy. Typically, client feedback is provided regularly throughout the course of therapy. Clients fill in a questionnaire about how they feel about the therapy and how they are feeling in general. The questionnaire is then scored and reviewed by the therapist. The idea is that the therapist will use the feedback to adjust the therapy process, aiming to improve the client-therapist and client-therapy fit and, ultimately, client involvement, treatment response and outcomes. There is empirical evidence for the use of client feedback in adult psychotherapy to improve outcomes and response, but there is limited knowledge about this practice in children and adolescents. This review can provide a better understanding of the current role of client feedback in psychotherapy for children and adolescents, as well as future directions that promote evidence-based practice in child and adolescent psychotherapy.

Who will be interested in this review?

Psychotherapists working with children and adolescents, policy makers, children and adolescents with mental health problems, and their caregivers and relatives.

What questions does this review aim to answer?

Some research suggests that client feedback has a positive impact on outcomes of psychotherapy with adults. We do not know whether client feedback works with children and adolescents.

Which studies were included in the review?

To be included in the review, studies had to be randomised controlled trials, where children and adolescents with mental health problems were allocated at random (by chance alone) to receive either psychotherapy with client feedback or standard psychotherapy. We searched electronic databases to find all such trials published up until 3 April 2018, and found six (with a total of 1097 children and adolescents) that met our inclusion criteria.

What does the evidence from the review tell us?

There have been few investigations of client feedback in psychological therapies for children and adolescents with mental health problems. Most of them were carried out in the USA with older children and adolescents (11 to 18 years old).

There was no clear evidence supporting the effectiveness of client feedback in psychological therapy for children and adolescents.

What should happen next?

It cannot be ruled out that client feedback has positive effects on psychotherapy outcomes in children and adolescents. High-quality studies are needed to provide sufficient evidence. Future studies should also include younger children, and should take place in countries other than the USA.

Authors' conclusions: 

Due to the paucity of high-quality data and considerable inconsistency in results from different studies, there is currently insufficient evidence to reach any firm conclusions regarding the role of client feedback in psychological therapies for children and adolescents with mental health problems, and further research on this important topic is needed.

Future studies should avoid risks of performance, detection and attrition biases, as seen in the studies included in this review. Studies from countries other than the USA are needed, as well as studies including children younger than 10 years.

Read the full abstract...

Childhood and adolescent mental health problems are a serious and growing concern worldwide. Research suggests that psychotherapy can have a significant and positive impact on children and adolescents with mental health problems, such as anxiety disorders, depression and conduct disorders. Client feedback tools serve as a method of monitoring clients' progress and providing feedback from clients to therapists during the therapeutic process. These tools may help to enhance clinicians' decision-making by allowing them to adapt their treatment plans as the therapy progresses, resulting in a reduction of treatment failures. Research has shown that client feedback tools have a positive effect on adults' psychotherapy. This review addresses whether feedback tools in child and adolescent therapy could help therapists to better treat their young clients.


To assess the effects of client feedback in psychological therapy on child and adolescent mental health outcomes.

Search strategy: 

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR, Studies and References), the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1946-), Embase (1974-) and PsycINFO (1967-) to 3 April 2018. We did not apply any restriction on date, language or publication status to the search.

Selection criteria: 

We included randomised controlled trials (RCTs) that compared client feedback to no client feedback in psychological therapies for children and adolescents.

Data collection and analysis: 

Two review authors independently assessed references for inclusion eligibility and extracted outcome, risk of bias and study characteristics data into customised forms. We contacted study authors to obtain missing data. We analysed dichotomous data using risk ratios (RRs) and calculated their 95% confidence intervals (CIs). For continuous data, we calculated mean differences (MDs), or standardised mean differences (SMDs) if different scales were used to measure the same outcome. We used a random-effects model for all analyses.

Main results: 

We included six published RCTs, conducted in the USA (5 RCTs) and Israel (1 RCT), with 1097 children and adolescents (11 to 18 years old), in the review.

We are very uncertain about the effect of client feedback on improvement of symptoms, as reported by youth in the short term because we considered evidence to be of very low-certainty due to high risk of bias and very serious inconsistency in the effect estimates from the different studies. Similarly, we are very uncertain about the effect of client feedback on treatment acceptability, due to high risk of bias, imprecision in the results, and indirectness of measuring the outcome (RR 1.08, 95% CI 0.73 to 1.61; 2 studies, 237 participants; very low-certainty).

Overall, most studies reported and carried out randomisation and allocation concealment adequately. None of the studies were blinded or attempted to blind participants and personnel and were at high risk of performance bias, and only one study had blind outcome assessors. All of the studies were at high or unclear risk of attrition bias mainly due to poor, non-transparent reporting of participants' flow through the studies.