to the editor: The article "Attention-Deficit/Hyperactivity Disorder: Management,"¹ by Drs. Szymanski and Zolotor, is a good general primer on this condition. This article addresses the major diagnostic criteria for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) according to guidelines in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and treatment with stimulants and other medications. However, the authors only briefly address parental education, school-related issues, and counseling.

Medication is an important and, sometimes, essential component in managing children with ADHD, but family physicians need to understand that simply prescribing medication and sending the child off to special education only touches the surface of the role that they can play. I urge that we as family physicians develop a better understanding of the school-related issues that face children with ADHD.

As the authors mention, children with ADHD have basic learning issues, including difficulties with concentration, attentiveness, impulsivity, hyperactivity, organizational issues, planning and other skills known as “executive functioning,” and are often poor readers. Children with ADHD are often bright, but many lack the visual processing skills needed to read, they focus poorly, and they suffer from many characteristic learning disabilities. Because of these factors, they often learn by different modalities than other children.

The traditional classroom environment is often too rigid and not easily adaptable to children with ADHD. These children often cannot do the work that other children do, and without recognition of these school issues, they often get further and further behind. Because they cannot do the work in the same way as the other children, their intelligence is rarely recognized. As a result, their behavior simply gets worse and they get bogged down with behavioral consequences instead of getting the kind of learning experience in which they can excel. Other methods of instruction and evaluation should be considered. Placing children with ADHD in special education classrooms is often not the answer. Many special education programs are underfunded, and children with ADHD are often mixed in with children who have serious developmental delays or have more serious psychiatric conditions. Teachers and educators must understand the neurophysiology of ADHD, how it impacts behavior, and how it impacts a child's ability to learn. ADHD must be recognized early, so that learning issues can be addressed with the same urgency as behavioral issues. Children with ADHD need to be evaluated by the school as early as possible; they should be instructed differently, and they should be evaluated differently according to their strengths and weaknesses.

Family physicians need to take a more aggressive stance in making sure that children with ADHD get the appropriate school evaluation, assistance, classroom modifications, support, understanding, and remediation. The school environment is essential to the success of treatment. If a school district is not providing the kinds of educational services that are required for any chance of success for these children, it is the responsibility of family physicians to involve themselves in less traditional ways.

in reply: Many students with attention-deficit/hyperactivity disorder (ADHD), when diagnosed early and treated with an appropriate medication regimen, do not require special education services or long-term counseling. These students can return to and succeed in mainstream education. Early diagnosis and treatment can prevent the negative self-image and dysfunctional compensatory behaviors. However, there are students who have a variety of learning disabilities that exist as co-morbidities that need to be identified and addressed. The ability and/or willingness of any public school system to help identify the problem and provide the necessary assistance is extremely variable. This support is influenced by school and governmental administrations, public and parental attitudes, and the amount of federal, state, and local money budgeted for this purpose.