General principles

Clinical management is guided by the knowledge that AD-HKD is a chronic condition that affects most aspects of a child's life and that is, in turn, shaped by a wide range of biological, psychological, and social factors (see Ch§pt§L2.:5.1). Consequently, a comprehensive assessment is the logical starting point for the management of a child with AD-HKD. This assessment must identify core AD-HKD symptoms, associated impairments in language and learning, and the concurrent emotional and behavioural conditions that frequently accompany the disorder. The treatment plan must consider the child's social context, including the quality of current schooling, the nature of parenting practices, and the extent of the parents' psychopathology. The longitudinal nature of the disorder dictates the need for a consistent case manager. Treatment must be flexible, both in kind and in intensity, to reflect the social, physiological, and cognitive developments and variations in the life situations of each child and his or her family.

Based on the available evidence, medication plays an important role in the treatment of AD-HKD. However, drug treatment must be instituted in the context of a comprehensive treatment plan. Rarely is medication prescribed as the sole treatment. For some children and families, medication will be an undesirable therapeutic option; for others, medication may be unnecessary or premature.

In clinical practice, however, physicians do encounter families who are not ready for or capable of undertaking treatments other than those involving medication. For many of these families, a period of behavioural improvement resulting from successful drug therapy may provide the impetus for entry into other essential non-pharmacological components of therapy. Some families may not consider non-drug interventions until they observe that an immediate increase in academic productivity does not necessarily translate into better grades at the end of the year, and that teachers' reports of improved behaviour at school do not ensure improved family relationships in the evenings. Other families may be too chaotic to use medications appropriately and may first need to try non-drug interventions under very close supervision or in an inpatient setting. Some families are more content with the decision to use medication if it follows a period of counselling or behavioural intervention.(204)

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