Children and adolescents in community mental health settings often present with multiple overlapping syndromes, as well as confounding issues such as family turmoil, abuse and neglect, and involvement with social welfare and juvenile justice systems. Most interventions proven to have efficacy in randomized, controlled trials have nevertheless not been well studied in complex clinical populations with diagnostic and psychosocial comorbidity. This column focuses on a case example with such confounding issues to highlight the challenges facing clinicians who seek to blend their own skills and the evidence base in providing effective treatment. The case used is a composite of clinical presentations commonly seen at the Child Study and Treatment Center, the long-term psychiatric hospital for youth in Washington State.