Intervention: First Principles 307treatment methods rather than vague, diffuse or mixed approaches; and
the use of structured therapy methods (for example, through treatment
manuals), with sufficient monitoring to ensure that therapists consistently
adhere to treatment plans. Good training programmes and ongoing expert
supervision help therapists to deliver evidence-based treatments with
fidelity to the intended approach. Conversely, there is increasing evidence
that lower levels of therapist skill lead to less good outcomes.
It obviously makes good sense to use treatment approaches that have
been shown to work. In practice, though, it is not possible to rely just
on published trials and protocols. For example, formal trials are usually
on children who meet the full diagnostic criteria for operationalised syn-
dromes, whereas many clinic cases have diffuse or partial syndromes that
do not meet these criteria. How should they be treated? Comorbidity is also
an important issue: the presence of more than one condition in the same
person is the rule in clinical practice rather than the exception. So if a child
has three comorbid diagnoses, should the child be given three manualised
treatments in succession or simultaneously? There is almost no evidence
on the best approach for comorbid disorders. In addition, a child or family’s
circumstances and preferences may make standard protocols unworkable.
There is clearly still a key role for clinical judgement and improvisation –
extrapolating from published evidence on what works, but not following
it slavishly. Finally, for less severe cases who are well motivated, there
is a growing evidence base that encouraging families to work though a
suitable self-help book or website can be effective, especially if backed up
by modest support, for example, fortnightly phone calls.
Modify treatment according to outcome
Having decided on a course of treatment, it is not enough just to give
the treatment; it is also important to monitor the outcome. The treatment
goals should have been recorded at the outset. Have these been attained?
This can be judged clinically, though it is often helpful to seek independent
corroboration, for example, by administering short questionnaires to the
child or adolescent being treated, to parents or to teachers. If the goals have
not been attained, it is often sensible to reassess the individual and review
the formulation before giving up or pressing on with more of the same.
Perhaps the individual has been resistant to treatment because the initial
diagnosis was wrong: a revised formulation may suggest a revised treat-
ment. Even if the original formulation still seems correct, it may be appro-
priate to switch to a different treatment. Even when trials have shown that
treatment X usually works better than treatment Y, a minority of patients
may respond better to Y than to X. If the individual and family are keen, a
second-choice treatment can be tried when the first-choice treatment fails.
There is an increasing trend in services to undertake routine monitoring
of outcomes. As the service develops, the progression may go from (1)
measures at initial assessment only to (2) assessment initially and at
termination or after, say, six months, to (3) repeating the measures after