Child and Adolescent Psychiatry

Intervention: First Principles 303

Symptoms and social impairments both need
to be addressed

Treatment is unlikely to be effective if the problem has not been char-
acterised accurately. The most skilled therapist will not get very far if
an important contributory factor has been overlooked and is preventing
progress. Therefore, an accurate assessment and formulation is essential
before embarking on a management and treatment plan. It is often a mis-
take to focus exclusively on psychiatric symptoms. As described in Chap-
ter 1, a psychiatric disorder should usually only be diagnosed if two con-
ditions are met: (1) the child has a recognised constellation of symptoms;
and (2) these symptoms have a significant impact. This adverse impact
often takes the form of social impairment affecting home life, schoolwork,
friendships or leisure activities. Both symptoms and social impairment
may need to be targeted by the intervention plan. Thus, with a depressed
adolescent, treating the low mood and sleeping problems may not be
enough. It may also be essential to decide how to tackle the issue of lapsed
friendships, and work out a plan for catching up with missed schoolwork
and even where symptoms may be hard to tackle directly, much good may
be done through promoting skills and self-esteem, for example, by getting
children to develop their interest in sport by joining a club where they are
encouraged to develop their ability and are appreciated by their peers.

Complex problems may need complex solutions

The sorts of problems that present to child mental health specialists
are rarely simple. Take, for example, a boy who presents with conduct
problems. A careful assessment may suggest that all of the following are
relevant:

an inherited tendency to hyperactivity;

dietary intolerance to citrus fruits and additives;

specific reading difficulties;

a tendency to see other people as hostile when they are not;

a family environment that has trained him to act coercively to get

attention and avoid demands;

inadequate parental supervision;

membership of a deviant peer group.

Perhaps tackling just one of these factors can help; the resultant im-
provements in one area may break a vicious cycle and allow the child
to recover. More often, however, clinical experience suggests that it is
necessary to target several problem areas at once. Interventions for child
mental health problems may target:

the child’s physiological function, for example, diet, medication;

the family’s knowledge of a condition, for example, explanatory leaflets;