Editorial perspective: Treatment of complex maltreatment - beyond the NICE guideline? Manuals, muddles or modules

Providing adequate treatment services for maltreated children is a considerable challenge. The recently updated NICE guideline on Child abuse and neglect (NICE guideline [NG276] 2017, London) includes recommendations on intervention for a variety of parenting contexts, and different forms of maltreatment at various stages of identification: 'Early Help for families showing possible signs of abuse and neglect', and 'Therapeutic interventions for children, young people and families, after child abuse and neglect'. The fifteen evidence-based manualised approaches to be considered for use by practitioners are valuable and backed up by appropriate research on effectiveness. Approaches are selected which could be applied to more than one form of maltreatment. However, the manualised approaches reviewed by NICE have differing theoretical frameworks and attempting to put together an intervention for more complex forms of maltreatment, based solely on these approaches, may result in confusion and muddle. In practice, polyvictimisation or multipart maltreatment is now seen as the rule, rather than the exception. In these cases, whole sibships may be affected, with children of different ages and stages of development presenting with differing needs. As a result, there is a cumulative, negative impact on their health and development. As Macdonald et al. (Health Technology Assessment, 2016, 20, 1) state, 'Most children experience more than one form of maltreatment, and there is growing recognition of the need to better take into account children's profiles of maltreatment in order to improve policy and practice' (p. 38). Marchette and Weisz (Journal of Child Psychology and Psychiatry, 2017, 58, 970) draw attention to the paradox that there are many focal treatment manuals in the child mental health field, which have contributed to practice, but which are not used widely in everyday practice, due to a focus on single disorders rather than the reality of comorbid, co-occurring problems. Few practitioners or service providers have the time or resources to learn a different approach for each disorder or problem type. A solution is the development of modular approaches. Effective practice elements can be 'distilled' from the intervention approaches recommended by NICE and from other evidence-based interventions identified (Bentovim and Elliott, Journal of Clinical Child and Adolescent Psychology, 2014 43, 270). Practice elements can be integrated into a flexible modular approach to intervention which can be tailored to fit the complex profiles of those maltreated children, young people and their families whom practitioners work within their everyday practice.