Feenstra et al. BMC Pediatrics 2014, 14:109
http://www.biomedcentral.com/1471-2431/14/109

RESEARCH ARTICLE

Open AccessInterventions to support children’s engagement
in health-related decisions: a systematic review
Bryan Feenstra1, Laura Boland1,2, Margaret L Lawson2,3, Denise Harrison1,2, Jennifer Kryworuchko4,
Michelle Leblanc5 and Dawn Stacey1,6*

Abstract
Background: Children often need support in health decision-making. The objective of this study was to review
characteristics and effectiveness of interventions that support health decision-making of children.
Methods: A systematic review. Electronic databases (PubMed, the Cochrane Library, Web of Science, Scopus,
ProQuest Dissertations and Theses, CINAHL, PsycINFO, MEDLINE, and EMBASE) were searched from inception until
March 2012. Two independent reviewers screened eligibility: a) intervention studies; b) involved supporting children(≤18 years) considering health-related decision(s); and c) measured decision quality or decision-making process
outcomes. Data extraction and quality appraisal were conducted by one author and verified by another using astandardized data extraction form. Quality appraisal was based on the Cochrane Risk of Bias tool.
Results: Of 4313 citations, 5 studies were eligible. Interventions focused on supporting decisions about risk behaviors(n = 3), psycho-educational services (n = 1), and end of life (n = 1). Two of 5 studies had statistically significant findings:i) compared to attention placebo, decision coaching alone increased values congruence between child and parent,
and child satisfaction with decision-making process (lower risk of bias); ii) compared to no intervention, a workshop
with weekly assignments increased overall decision-making quality (higher risk of bias).
Conclusions: Few studies have focused on interventions to support children’s participation in decisions about theirhealth. More research is needed to determine effective methods for supporting children’s health decision-making.
Keywords: Child, Adolescent, Decision making, Patient participation, Practice

Background
The perspective of the child is important when making
decisions about his or her health [1-3]. When children are
involved in decision-making, they experience decreased
anxiety and an increased sense of value and control [3,4].
Their involvement is also thought to improve communication between children, parents and clinician(s); which
is important for child/parent satisfaction and may also
improve adherence with the chosen treatment [5,6]. The
practice of including children in decision-making is also
advocated by several prominent organizations. In 1989,
the United Nations Convention on the Rights of a Child(UNCRC) provided grounds for a child’s right to be* Correspondence: dstacey@uottawa.ca
1
University of Ottawa, Faculty of Health Sciences, Ottawa, ON, Canada
6
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,
ON, Canada
Full list of author information is available at the end of the article

involved in decisions regarding his or her health [7]. The
American Academy of Pediatrics Committee on Bioethics
recommends that children should be included in decisionmaking to the greatest extent possible [8]. Children’sability to make health decisions is influenced by multiple factors such as developmental stage, experience
with the disease, and parental and health professional attitudes about the child’s capacity [9,10]. For example, in a
recent study involving children with Type I diabetes making decisions with their parent and healthcare team, children as young as 8 years old were successfully recruited[11]. Therefore, the extent that children can participate inhealth decisions should depend on their ability and nottheir chronological age. As such, children’s competence
should be assessed on an individual basis and in relation
to the decision being made. Nonetheless, lack of competence should not be a reason to restrict children’s right toparticipate in decisions about their health [9].

© 2014 Feenstra et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Feenstra et al. BMC Pediatrics 2014, 14:109
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Despite benefits and clear mandates for including children, studies show that children are not sufficiently involved and their preferences are not being elicited asoften or consistently as they could be [9,10,12,13]. Furthermore, although most clinicians recognize the needto include children in decision-making, they have varying opinions about when and how to do so [14]. Factors
such as the child’s age, length of illness, previous experiences, clinical condition, behavior, and ability to express
oneself are often considered when deciding whether or
not to include him or her [1,14,15]. As a result, children
are often excluded, which may lead to fear, confusion,and anger on the part of the child [3,16].
A Cochrane review examined the effects of interventions
that enhance general communication between health professionals and children with cancer [17]. Although someinterventions demonstrated some benefit to children by
improving knowledge, psychological support, and reintegration into school and social activities, the communication interventions in this review were not designed
to address children’s decision-making needs. Another
Cochrane review of interventions to support shareddecision making in children with cancer had no studies that meet the inclusion criteria [18]. No other systematic review has specifically explored interventions
tailored to support children in their health-related decisionmaking. The purpose of this systematic review was toexplore the characteristics and effectiveness of interventions that support the decision-making needs ofchildren who are actively considering a health-related
decision.

Methods
A systematic review was conducted using a protocol developed a priori based on the Cochrane Handbook for
Systematic Reviews of Interventions [19]. Studies including

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children who were actively facing a health-related decision
with or without their parent(s)/guardian(s) were considered for inclusion (see Table 1). Children were defined
as individuals aged 18 years or younger [7]. Studies
needed to evaluate an intervention that addressed an
identified decision-making need of the child. Study designs considered were randomized controlled trials (RCTs),
non-randomized controlled trials (non-randomized CT),
interrupted time series (ITS), and controlled beforeand-after (CBA) designs. Comparator groups could havebeen usual care or any alternative intervention. Study outcomes needed to address either the quality of the decision(e.g., knowledge, values-choice agreement) or the decisionmaking process (e.g., decisional conflict, satisfaction) for
children. These outcomes are based on the International
Patient Decision Aids Standards [20] and are consistent
with systematic reviews of interventions to support adults
and parents in making health decisions [21,22].
Search strategy

The following electronic databases were searched: EvidenceBased Medicine Reviews (Ovid) (Cochrane Database of
Systematic Reviews (Issue 2, 2012), Database of Abstractsof Reviews of Effects (1st quarter 2012), Cochrane Central
Controlled Trials Register (Issue 2, 2012)); MEDLINE(Ovid) (1966 to March 2012); MEDLINE (PubMed) (1945to March 2012); CINAHL (via EBSCOhost) (1981 toMarch 2012); PsycINFO (1806 to March 2012); Web of
Science (1898 to March 2012); Scopus (1960 to March2012); ProQuest Dissertations and Theses (1861-March2012); EMBASE (Ovid, 1974 to March 2012). The Agency
for Healthcare Research and Quality (AHRQ) website(under Children’s Health) and Google Scholar were also
searched informally using key words from the search strategy. Finally, reference lists of included articles and review
articles were scanned.

Table 1 Inclusion/exclusion criteria for article eligibility
Included

Excluded• Children (≤ 18 years) who are facing a health-related decision• Children not treated as active participants in decision-making• Decisions about participation in health research• Decisions not directly pertaining to their health or hypotheticaldecisionsInterventions• Interventions to support children’s decision-making needs• Interventions that support only the information needs of children

Design• Randomized controlled trials• Qualitative studies, descriptive studies, cohort studies• Non-randomized controlled trials• Editorials, opinion articles

Participants• Interrupted time series• Controlled before-and-after
Outcomes• Outcomes that affect the quality of the decision or thedecision-making process for children/youth• Studies that do not report at least one of the outcomes relating
to the quality of the decision or the decision-making process

Language• English or French• Other languages

Publication
status• Published• Unpublished studies• Peer-reviewed• Non peer-reviewed

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The search strategy included a mix of subject headings
and keywords related to the intervention (e.g., intervention,
patient participation, social support, health communication), decision support techniques (e.g., decision-makingcomputer-assisted, decision trees), and decision-making(see Table 2). Some limits were applied relating to study
types (e.g., clinical trials, or randomized controlled trials,
or evaluation studies), language (English or French only),and participant types (must include child or adolescent).
Study selection

After removing duplicates, retrieved article citations were
uploaded onto a web-based screening application designed
by our research team’s information technologist. This
program allows independent reviewers to evaluate study
eligibility through a multi-stage screening process: titles,
abstracts, and full-text. First, references identified by thesearch are loaded into the title screening application andrandomly assigned to reviewers for initial screening. Excluded titles are assigned to another reviewer for screening. Reviewers do not know if they are screening first or
second. All included citations then move to the second(abstracts) screening stage, using the same process. Title
and abstract screenings were completed by BF and at least
one other reviewer (LB, DS, ML, JK). Full-text versions
were reviewed manually for final inclusion by BF and LB.
Disagreements between reviewers were resolved by consensus or by consulting a third member (DS) of the review
team.
Data collection

Data extraction was conducted by BF and verified by a second review author (LB). The process was guided by a data
Table 2 Search strategy used for Pubmed

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extraction form based on one used in another systematic
review of decision support interventions [22]. The data extraction sheet was piloted with a randomly selected study
chosen for inclusion and necessary revisions to the form
were made. Disagreements between review authors regarding data extraction were resolved by discussion.
The following information was extracted from each study(as per the data extraction sheet): a) characteristics ofchild participants (location, age, gender, ethnicity, diagnosis, and stage of illness), b) study methods (aims, design,
allocation, recruitment, inclusion/exclusion criteria, informed
consent, ethical approval, funding, and statistical methods),c) intervention(s) and control intervention(s) (enrollment
and attrition of participants, type(s), co-interventions, content, mode of delivery, timing, frequency, duration, provider,training, and elements of decision support), d) outcomes(primary and secondary measures, definition(s), methodsof follow-up, timing, validity of instruments used andadverse events), e) results (according to study type), andf) limitations and conclusions indicated by the original
authors.
Risk of bias assessment

The Risk of Bias tool from the Cochrane Handbook wasused to assess RCTs [19]. Risk of Bias tables adaptedusing guidelines developed by the Cochrane Effective
Practice and Organization of Care Review Group [23]were used to assess studies with non-randomized CT, ITS
and CBA designs.
Quality assessment was completed independently by
two reviewers (BF and a research assistant). Disagreement was resolved through discussion, and when unsuccessful, a third reviewer (DS) arbitrated. As suggested by
the Cochrane Handbook, the following types of bias
were assessed as “high risk”, “low risk”, or “unclear risk”:a) selection bias (random sequence generation and allocation concealment), b) performance bias (blinding ofparticipants and personnel), c) detection bias (blinding ofoutcome assessment), d) attrition bias (incomplete outcome data), e) reporting bias (selective reporting), andf ) other bias.

Group

Searched terms

1intervention* OR intervene* OR "Health Knowledge, Attitudes,
Practice" [Mesh] OR "Social Support" [Mesh] OR "Family" [Mesh]
OR "Patient Participation" [Mesh] OR "Health communication"[Mesh] OR "Health education" [Mesh] OR "Decision Support
Techniques" [Mesh] OR "Decision Making, Computer-Assisted"[Mesh])

2("Decision Making" [Mesh])

Measures3(Humans [Mesh])

4(Clinical Trial [ptyp] OR Meta-Analysis [ptyp] OR Randomized
Controlled Trial [ptyp] OR Review [ptyp] OR Classical Article[ptyp] OR Comparative Study [ptyp] OR Controlled Clinical Trial[ptyp] OR Evaluation Studies [ptyp] OR Historical Article [ptyp]
OR Journal Article [ptyp] OR Multicenter Study [ptyp] OR
Patient Education Handout [ptyp] OR Validation Studies [ptyp])5(English [lang] OR French [lang])

7

1 AND 2 AND 3 AND 4 AND 5

8(infant [MeSH] OR child [MeSH] OR adolescent [MeSH])

97 AND 8The primary outcomes of interest for this systematic review
were those that improved decision quality: knowledge regarding the decision and options, accuracy of perceptions
regarding benefits and harms of treatment options, andagreement between values and chosen option. Secondary
outcomes were those that improved the decision-making
process: satisfaction with process, decisional conflict, participation in decision-making process, communication withhealth professional and parent(s)/guardian(s), and proportion undecided. Outcome results were presented as reported in studies.

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Data synthesis

The limited number of eligible studies and heterogeneity
in interventions, study design and outcomes precluded
the pooling of results for meta-analysis. A descriptive synthesis was therefore conducted. The synthesis of findings
was structured using the following domains: characteristics of studies, interventions, and outcome measures; andimpact of interventions. Studies with similar interventions
were grouped together. The following intervention categories were used: a) decision coaching alone (coaching),b) coaching plus an educational aid, and c) education
alone. Essential elements of decision support interventions
were identified with criteria previously used to evaluate
decision support technologies and general SDM interventions [22,24-26].

Results
Studies selected

The search identified 6051 citations. After removing duplicates, 4313 original articles were screened (see Figure 1).
Of these, 4201 citations were removed after title and abstract screening because they did not meet the inclusion
criteria. The full text reports of 112 citations were retrieved and 107 citations were excluded. The results of 1
study were published in 2 papers; therefore, after retrieving the additional paper, this review included 5 studies
published in 6 papers.

Figure 1 Literature flow diagram.

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All 5 studies were conducted in the United States andpublished in English (see Table 3). Three studies publishedsince 2008 were RCTs [27-29] and 2 studies published
before 2000 were a non-randomized CT [30] and a CBA
study [31]. Studies included a variety of decision types including participating in risk behaviors (n = 3), choosing a
psycho-educational service to overcome learning problems (n = 1), and end of life planning (n = 1). Four studies
were conducted in a clinical setting and 1 was conductedin a day camp.[31] Sample size of participants in included
studies ranged from 38 to 819 (median 64). Three studies
were conducted with children who had a chronic medical
condition (asthma, HIV or cancer) [28,29,31,32] and 2
were conducted with children without any previous medical concerns [27,30]. Of the 5 included studies, 2 RCTs
were rated as lower risk of bias, 1 RCT had an unclear
risk of bias due to vague reporting, and 2 non-RCTs had
higher risk of bias (see Table 3) [30,31].
Decision support interventions

Decision support interventions were decision coaching[27-30,32] or an educational workshop [31] and were accompanied by computer programs, workbook exercises,
telephone follow-ups, and information packages. Control
groups received no intervention [31] and/or an attention
placebo such as a computer program, coaching, or information package on another topic not related to theAuthor(year)

Study design

Rhee, 2008 RCT[28]

Lyon, 2009 RCT[27,31]

Adams,
2009 [26]Hollen,1999 [30]

Adelman,1990 [29]

RCT

CBA

Decision

Participants (n) and setting

ComparisonsPrimary outcome(s)Quality assessment

Partaking in risk
behaviors

41 children with asthma (20a + 21b);
4 rural outpatient clinics and 1 highschoolCoaching and computer
based program v. attention
placeboFeasibility of the decision-making
programd: Low Riskge

: Low Riskhf

: Low Riski

Communication quality,
congruence of treatment
preferences, decisional conflictsatisfactiond: Low Risk

gge

: Low Riskhf

: Unclearii

Sun protection behaviors, pros forprotection, pros for exposure,decisional balanced: Unclearge: Unclearhf: Low Riskid

: High Riskge

: High Riskhf

: High Riskid

: High Riskge

: High Riskhf

: High Riski

End of life decisionmaking

40 children with HIV and theirparents (21a + 19b); 2 hospital
outpatient clinics

Sun exposure v. sun 819 children (395a + 424b); primary
protection
care physicians office

Partaking in risk
behaviors

Non-randomized Psycho-educationalCT
decision-making

64 cancer-surviving children(21a + 43c); campground

85 families (32a + 20b + 33c);
university clinic

Coaching v. attention
placebo

Coaching and computer
program v. attention placeboWorkshop and weekly
assignments v. nointervention
Pre-conference coaching v.
no intervention v. attention
placebo

Decision-making, risk motivation,risk behaviors

Child participation: Low Riskj

: Low Risk

: Unclear: Unclear: Unclearj: Low Risk

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Table 3 Characteristics of included studies (N = 5)

: Low Risk

: Unclear: Unclearj: Low Risk

: Unclear: Unclear: Unclearj: Low Risk

: Unclear: Low Risk
: High Risk j: Low Risk

: Unclear: High RiskaIntervention group.
Placebo group.
No intervention group.
dRandom sequence generation.
e
Allocation concealment.
fBlinding of participants AND personnel.
gBlinding of outcome assessment.
hIncomplete outcome data.
i
Selective reporting.
j
Other sources of bias.
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decision (see Table 4) [27-30,32]. Of the 12 essential
elements of decision support interventions, [33] 1 study
addressed 11 elements, [28,32] 3 studies addressed 6 elements, [27,29,31] and 1 study addressed 4 elements (seeTable 5) [30].
Outcome measures

Four studies had 1 or more primary outcomes related todecision quality [27,28,30-32] and 2 studies had 1 ormore outcomes related to the decision-making process[28,30,32] (see Table 6). Quality of decision-making wasmeasured in 2 studies using the Decision-Making Quality Scale [34]. Satisfaction with the decision-making
process was measured in 2 studies using unpublishedscales. Other decision-making outcomes included: agreement between values and chosen option, congruence oftreatment preferences between child and parent, participation in decision-making process, decisional conflict,and communication [27,28,30,32]. Outcomes that were
not related to decision quality or the decision-making
process were sun protection behaviors, [27] motivational
readiness and future motivation, [30] risk motivation
and actual risk behaviors (e.g., smoking, alcohol use,
and illicit drug use), [29,31] and feasibility of a decisionmaking program [29].
Effectiveness of interventions
Decision coaching alone versus attention placebo/no
intervention (n = 2 studies)

Two of the 5 studies compared coaching with an attention placebo or no intervention (Table 6) [28,30,32]. In
the Lyon study, [28] decision coaching consisted of trained
facilitators who elicited and stimulated conversation about
patients’ views and opinions about their disease. In the
Adelman study, decision coaches encouraged children toparticipate, and facilitated a discussion about participation
strategies. Then the decision coach and child rehearsed
participation strategies [30].
For decision quality outcomes, 1 study [28] reported
improved values congruence between parent and childfor 1 of the 3 scenarios tested. There were no statisticallysignificant differences for the low survival and functional
impact scenario (as it related to HIV end of life decisions);
however, improved parent–child congruence was found
for the cognitive impairment scenario (69%; CI 0.45-0.90
vs. 11%; CI 0.05-0.25, congruence) [28].
For decision-making process outcomes, Lyon and colleagues [32] found that children were more satisfied withthe decision-making process (P = 0.001) while anotherstudy [30] reported no difference. One study [28] foundno difference in decisional conflict scores (except for a
sub-score relating to feeling informed (P = 0.001), and nodifference in the quality of child-decision coach communication. One study [30] found no difference in the

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child’s level of participation in health decision-making.
Original reports on the decision-making process outcomes
did not include descriptive statistics of outcome measurescores.
Coaching plus educational aid versus attention placebo/no
intervention (n = 2 studies)

For decision quality outcomes, coaching combined witha co-intervention had no effect on agreement between
participants’ values and their chosen behavior when compared to an attention placebo in 1 study [27]. There wasno difference in overall quality of decision-making whencompared to an attention placebo in the other study [29].
Education alone versus attention placebo/no intervention(n = 1 study)

In one study, an educational workshop with weekly assignments increased decision-making quality in one ofthree scenarios presented. Compared to the control group,
the intervention decision-making quality scores improvedin the cognitive impairment scenario at 1 (mean differenceof 0.34 vs. 1.62, P = 0.02) and 12 months (−0.38 vs. 1.79,
P = 0.001), but not 6 months post-intervention (mean difference of 0.23 vs. 1.05, P = 0.10) [31]. Higher scores indicate better decision quality.

Discussion
This systematic review was designed to evaluate thecharacteristics and effectiveness of interventions that
support children in health decision-making. Althoughinterventions to support decision-making in the adultsetting have been well tested, [22] the evaluation of formal interventions supporting pediatric health related
decision-making is lacking. Our systematic review identified only 5 studies of which 4 evaluated decision coaching with or without a co-intervention aid (e.g., computer
programs, workbook exercises, information packages), 1
evaluated an educational workshop, and none evaluatedpatient decision aids with decision coaching. Interestingly however, 3 of the 5 studies included in this review
were published within the last 5 years, which may indicate a growing interest in evaluating interventions to
support children’s decision-making.
Two studies had statistically significant findings: coaching alone increased agreement between parent and childvalues (i.e., values congruence) between child and parent
as well as child satisfaction with the decision-making process(1 RCT), and education alone increased overall decisionmaking quality (1 CBA study). Three studies found no difference in decision-making quality, satisfaction with thedecision-making process, and child participation in decisionmaking (2 RCTs, 1 non-randomized CT). We could notcomment on the clinical significance of the findings
because either the scales used to measure the outcome

Study (year)

Group

Decision support program

Administered by:Intervention and timeline

Intervention duration

Rhee, 2008 [28]Decision support

Coaching guided by risk behavior fact sheet.
Computer-based decision-making module.

Healthcare Provider

Main intervention plus CD-ROM intervention
booster at 2 and 4 mo. post-intervention

Coaching = 10 min,Computer = 60 min,2 mo. Booster = 90 min

Intervention boosters: computer based decisionmaking module, workbook, and substanceprevention computer program.
Control

Sham computer program of comparable lengthfeaturing study skills.

4 mo. booster = 30 min
Participant directed

Computer program only

Comparable to theintervention program minus
the booster

No booster.
Lyon, 2009 [27,31]

Adams, 2009 [26]Hollen, 1999 [30]

Adelman, 1990 [29]Decision support

Three semi-structured interviews: 1. Lyon Family
Centered Advance Care Planning Survey, 2. The
Respecting Choices patient centered-ACP interview,
3. Five Wishes legal directive.

Trained Facilitator

Three sessions, 1 week apart180- 270 min. (for three
sessions)

Control

Three sessions re: 1. non-medical developmental
history, 2. safety information, 3. career planning.

Trained Facilitator

Three sessions, frequency not specified

Comparable to theintervention

Decision support

Brief coaching, interactive computer sessions,
telephone assessments, printed tailored feedback,a brief printed manual, mailed tip sheets, andsamples of sunscreen.

Healthcare provider/

Main intervention at baseline and
12 months

Coaching session = 2 to
3 min.

Participant directed

At 3, 6, 15, and 18 mo. children phoned forthe expert system assessments

Sun Smart System = 20 min

Not specified

ControlComputer program with monthly stage-matched
telephone calls, printed manual and mail at 24 mo.
Information related to physical activity, sedentary
behavior, total fat intake, and servings per day offruits and vegetables.

Trained Facilitator

Stage matched to intervention group

Decision support

Camp workshop integrating survivorship, quality
decision-making skills, children risk behaviors, andsocial support from peers and health professionals.
Follow up workbook exercises with audio-tape.

Trained Facilitator

Workshop plus 4 weekly assignments

Control

No intervention.

Decision support

Pre-conference coaching encouraging andfacilitating child’s participation in the conference.

Control

1. Attention placebo-expanded neutral explanationof the conference process.

Follow up assessments = notspecifiedWorkshop = 1 day.
Weekly assignments = notspecified

Not specified

Not specified

Trained Facilitator

Main intervention only

5 to 15 min

Trained Facilitator

Control 1: Explanation only

Control 1: Not specified

Control 2: Not specified

Control 2: Not specified

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2. No-intervention.

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Table 4 Characteristics of Decision Support Interventions (N = 5)

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Table 5 Elements of the decision support interventions (N = 5)
Intervention description

Rhee, 2008
[28]

Lyon, 2009
[27,31]

Adams, 2009[26]

Hollen, 1999[30]

Adelman, 1990
[29]

Type of intervention✓

Coaching alone✓

Coaching and educational aid✓✓✓

Education alone
Elements of decision support✓

Decision defined/explained
Assess/discuss patient’s decision-making needs

✓

✓

✓

✓

Options (including alternatives) presented

✓

✓

✓

✓

Benefits of options discussed

✓

✓

✓

✓

Risks of options discussed✓

Understanding assessed/clarified✓

Values/preferences discussed

✓

✓

✓

✓

✓

✓

✓

✓

Build skills in deliberation, communication, andaccessing support✓✓

Ability/self-efficacy to enact plan discussed✓

Decision made or explicitly deferred
Facilitate progress in decision-making

✓

✓

✓

6

11

✓

✓

✓

6

6

4

✓

Follow-up arranged
Total Elements✓= decision support element present.

Table 6 Summary of outcomes examined and statistical significance (N = 5)Comparisons

Coaching alone v. attention
placebo/No intervention

Coaching plus aid v. attention
placebo/No intervention

Study

Lyon 2009[27,31]

Adams 2009[26]

Adelman 1990
[29]

Education alone v. attention
placebo/No intervention

Rhee 2008[28]

Hollen 1999 [30]No statisticallysignificant
difference

Statistically significant at
1 P = 0.02 and 12 months
P = 0.001, but not 6 months
post-intervention

Decision quality
Overall quality of thedecision-making process

Congruence for values
and chosen option
Child–parent congruence
for treatment option
preference

No statisticallysignificant
difference
Statistically significant
difference on 1 of 3
scenarios

Decision-making process
Satisfaction

Statistically significant
for 2 of 3 intervention
components. (P = 0.001)

Participation

No statisticallysignificant
difference
No statisticallysignificant
difference

Decisional conflict

Statistically significant
informed sub-score(P = 0.001)

Communication

No statisticallysignificant differenceFeenstra et al. BMC Pediatrics 2014, 14:109
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lacked psychometric properties or the effect size of significant results were not provided in the original article.
Coaching was part of the decision support interventions in 4 of 5 studies. The study by Lyon and colleagues,[28,32] which was one of the higher quality studies that
met most elements of decision support, used a coaching alone intervention for end-of-life decision-making.
It found increased values congruence between childand parent, and increased child satisfaction with thedecision-making process compared to controls. Thesefindings are consistent with a systematic review of decision coaching interventions that found adults weremore satisfied when decision coaching was used alone
or in conjunction with patient decision aids compared
to usual care or a patient decision aid alone [35]. Interestingly, the positive study included in our review coachedboth parents and children together, [28,32] whereas otherstudies coached children only [27,29,30]. Decision coaching with both children and parents may be important forshared decision making within pediatrics as it can prepare
all stakeholders who have an impact on the outcome andimplementation of the decision [36,37].
Coaching was also provided together with educational
resources such as computer programs, workbook exercises, and information packages [27,29]. Adams and colleagues [26] demonstrated that participants could establish
clear values, and found correspondence between thosevalues and chosen behavior; however they did not find adifference based on intervention. Rhee and colleagues [29]also found no difference based on intervention. These
educational interventions appear to be similar to patientdecision aids, which help prepare individuals to make adecision with their health professional [22]. However,education alone may not fully support decision-making
as it does not address the patient’s contextual and social
influences [21,22]. A systematic review of the decisionmaking needs of parents concluded that parents require
not only timely, reliable, and current information but
also support for the preference-sensitive nature of manydecisions [21]. In contrast to the simple patient education resources evaluated in the studies included in thissystematic review, patient decision aids better support
SDM by also making explicit that a decision needs to be
made, providing values clarification, and guiding patients through a stepped approach to thinking about thedecision [22].
A review evaluating patient decision aids with adults
found they increase knowledge, accuracy of risk perceptions, and the consistency of decisions with patient
values [22]. Patient decision aids also lower decisional
conflict (related to feeling uniformed and having unclear
values), decrease indecision, and increase participation indecision-making. Since these interventions are successful
with adult populations, it is possible that educational aids

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that account for the social and values-dependent nature ofdecision-making may be an effective intervention withchildren. However, similar to decision coaching, little research has been conducted regarding their use with either
children and/or their parents.
There are several limitations that should be consideredwhen interpreting the results of this systematic review.
First, on an individual study level, there were few studies
from which to draw firm conclusions. Furthermore,
included studies lacked homogeneity with regards to patient context, interventions used, outcomes, and outcome
measures; thereby precluding the pooling of results formeta-analysis. The overall quality of included studies
ranged from low to high, with only 2 studies adequately
meeting the risk of bias criteria. Another limitation was
the lack of detail provided about interventions, potentiallypreventing an accurate assessment of the elements of decision support.
On a review level, although a thorough and systematic
approach was used to search the literature with two
independent reviewers screening citations, it is possiblethat relevant studies were missed. This review did notsearch trial registries and grey literature that may
have contained studies that could contribute understanding to this topic. This review may also have been
limited by restricting the search to English and French
articles [38].

Conclusions
Five studies, of variable quality, evaluated interventions
to support children in making health decisions, withmost of these studies published within the last five years.
Despite increasing interest in supporting children’s participation in health decision making, this systematic review affirms the need for further research examining
targeted interventions to support the involvement ofchildren in SDM. Future studies evaluating interventions to support children’s decision-making should use
rigorous designs such as randomized control trials or cluster randomized control trials, using outcome measureswith evaluated psychometric properties, and clear anddetailed reporting of decision support interventions
and results.
Abbreviations
RCT: Randomized controlled trial; SDM: Shared decision-making.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BF was involved in conception and study design, collection and analysis ofdata, wrote the first draft of the manuscript and edited and revised
subsequent drafts. MLB, ML, DH and DS participated in study design,collection of data, and edited and revised the article for important
intellectual content. JK and ML participated in data collection and edited

Feenstra et al. BMC Pediatrics 2014, 14:109
http://www.biomedcentral.com/1471-2431/14/109

and revised the article for important intellectual content. All authors
approved the final manuscript as submitted.
Acknowledgements
The research team would like to acknowledge the work of Sarah Beach who
acted as a second reviewer in the assessment of risk of bias and Anton
Saarimaki for his technical support.
Funding source
No funding was secured for this study.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Author details
1
University of Ottawa, Faculty of Health Sciences, Ottawa, ON, Canada.
2Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON,
Canada. 3Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada.
4
University of Saskatchewan College of Nursing, Saskatoon, SK, Canada.
5
University of Ottawa, Health Sciences Library, Ottawa, ON, Canada. 6Clinical
Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,
Canada.
Received: 20 November 2013 Accepted: 16 April 2014
Published: 23 April 2014
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doi:10.1186/1471-2431-14-109
Cite this article as: Feenstra et al.: Interventions to support children’s
engagement in health-related decisions: a systematic review.
BMC Pediatrics 2014 14:109.

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