Brogren Carlberg and Löwing reply

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Abstract

Please also see the reply to this letter by 503–504.

SIR–The letter from Wallen and Hoare pinpoints some of the questions that formed the basis of our review.[1] The research question grew initially from a study where we compared goal-directed, activity-focused intervention with activity-focused intervention alone.[2] As these two treatment approaches were relatively similar, but the approach containing the goal setting proved to be significantly more successful, we felt intuitively, as Wallen and Hoare suggest, that involving families in goal setting can positively improve treatment outcome in activity-focused intervention. However, after reading the randomized controlled trial (RCT) study by Law et al.[3] we reconsidered our assumption. They compared two treatment arms: (1) context-focused therapy, which contained goal setting; and (2) child- and activity-focused therapy, which lacked goal setting. The two approaches proved to be equally efficient. The fact that activity-focused interventions could be successful without setting treatment goals surprised us. Therefore we decided to explore studies investigating the link between activity-focused interventions and goal setting.

The conclusion of our review, as stated in the abstract, was that it did not ‘provide support for a positive effect of goal setting per se on treatment outcome’. Wallen and Hoare indicate that this conclusion is ‘ambiguous and potentially unintentionally misleading’. They suggest that a proper conclusion might instead be ‘We did not locate any studies which addressed the review question’. But this was not the outcome of our literature search. As stated on page 53 in our review, the study by Lammi and Law[4] investigated whether goal setting alone could influence treatment outcome. Unfortunately, the study was underpowered and did not allow any general conclusions. The study design, where more goals are set than addressed in therapy, provides a feasible opportunity in future research to address the question regarding the influence of goal setting per se. Furthermore, the design offers a possibility to deal with the heterogeneity within the group of children with cerebral palsy, which often causes difficulties when conducting RCT studies.[5]

Wallen and Hoare also mentioned that we might have concluded from the RCT studies by Wallen et al.[6] and Novak et al.[7] that ‘Goal setting alone may not be sufficient to effect meaningful change.’ This finding is in line with our conclusion that the review did not ‘provide support for a positive effect of goal setting …’ To avoid this phrase, which according to Wallen and Hoare can be misleading and associated with the six dangerous words (‘there is no evidence to suggest …’), we instead propose that ‘the scientific evidence is inconclusive …’ as recommended by Braithwaite[8] to be a more precise statement.

Setting specific treatment goals in everyday clinical practice is a way to emphasize activities the child and the family consider important for the child to learn. The process is experienced as positive both by parents and professionals and is consequently a natural part of family-centred practice.

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